JJSJJ.V.'jm'.V.MTCB.yy-aA:.- 


College  of  ^i)psiicians!  anb  ^urgeonis 
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PRACTICAL  TREATISE 


FMCTUEES   AND  DISLOCATIONS. 


BY 


MANK  HASTmGS  HAMILTON,  M.  D. 


'1 


PROFESSOR  OF  SURGERY  IN  THE  UNIVERSITY  OF  BUFFALO  ; 

SURGEON  TO  THE  BUFFALO  HOSPITAL  OF  THE   SISTERS  OP  CHARITY; 

CONSULTING  SURGEON  TO  THE  BUFFALO  GENERAL  HOSPITAL,  AND  TO  THE  BUFFALO  CITY  DISPENSARY. 


ILLUSTRATED     WITH 


TWO   HUNDRED  AND  EIGHTY-NINE    WOOD-CUTS. 


PHILADELPHIA: 
BL  AN  CHARD    AND    LEA. 

1860. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1860,  by 

BLANCHARD   AND   LEA, 

in  the  Office  of  the  Clerk  of  the  District  Court  of  the  United  States  in  and  for  the 
Eastern  District  of  Pennsylvania. 


PHILADELPHIA  : 
COLLINS,    PRINTER. 


TO 


YALENTIKE  MOTT,  M.D., 


IN  RECOGNITION  OF  HIS  JUSTLY  DISTINGUISHED  REPUTATION  AS  A  SURGEON, 

AND  IN 

TESTIMONY    OF    PERSONAL    ESTEEM, 

IS  RESPECTFULLY  DEDICATED 
BT 

THE    AUTHOR. 


PREFACE. 


The  Eno-lisli  lansfuao'e  does  not  at  this  moment  contain  a  sinsrle  com- 
plete  treatise  on  Fractures  and  Dislocations.  The  two  small  volumes 
of  Desault,  and  the  one  of  Boyer,  issued  near  the  close  of  the  last 
century,  and  translated  into  English  early  in  this,  may  perhaps  pro- 
perly enough  have  been  regarded  as  complete  treatises  at  the  time 
of  their  publication,  but  they  certainly  cannot  be  so  considered  now. 
The  several  chapters  on  ^'•Diseases  and  Injuries  of  the  Bones^''  contained 
in  the  Leqons  Orales  of  Dupuytren,  translated  in  1846,  and  the  Trea- 
tise on  Fractiires  in  the  Yicinity  of  Joints^  and  on  Certain  Forms  of 
Accidental  and  Congenital  Dislocations^  by  Robert  Smith,  are  invaluable 
monographs,  but  neither  of  them  claims  to  be  anything  more  than  a 
collection  of  occasional  and  miscellaneous  papers.  The  writings  of 
Amesbury  and  of  Lonsdale  relate  only  to  fractures.  Even  the  justly 
celebrated  quarto  of  Sir  Astley  Cooper  is  no  more  than  what  its  title 
plainly  declares  it  to  be,  A  Treatise  on  Dislocations  and  on  Fractures  of 
the  Joints;  but  since  the  announcement  of  the  present  volume,  a  trans- 
lation of  Malgaigne's  great  and  crowning  work  on  Fractures  and 
Dislocations  has  been  commenced  by  Dr.  Packard,  of  Philadelphia, 
and  the  first  volume  has  been  placed  in  the  hands  of  the  American 
profession.  Should  the  remaining  volume  be  rendered  into  English, 
the  gap  in  our  literature  will  be  measurably  filled. 

Under  these  circumstances  I  might  scarcely  have  thought  it  worth 
while  to  continue  my  labors,  already  so  near  their  completion,  had  it 
not  seemed  to  me  that  Malgaigne,  whose  researches  have  been  truly 
marvellous,  had  failed  in  some  measure  to  give  a  just  representation 
of  the  observations  and  improvements  which  have  been  made  from 
time  to  time  by  my  own  countrymen. 

The  contributions  of  American  surgeons  to  this  department  had  to 
be  sought  chiefly  in  medical  journals,  many  of  which  have  long  been 
discontinued,  and  most  of  which  were  inaccessible  to  the  great  French 
writer.  Even  to  an  American,  the  labor  of  exhumation  from  archives 
hitherto  almost  unexplored  has  not  been  small;  and  it  is  probable 


VI  PREFACE. 

that  many  valuable  papers  have  been  overlooked;  indeed  it  is  impos- 
sible that  it  should  be  otherwise. 

I  am  free  to  say,  also,  that  I  have  been  encouraged  by  a  hope  that 
my  own  personal  experience,  obtained  during  many  years  of  public 
and  private  service,  might  be  of  some  value  to  my  contemporaries. 

Very  little  space  has  been  devoted  to  what  is  now  only  historical, 
except  so  far  as  was  necessary  to  correct  certain  time-consecrated 
errors,  or  to  confirm  and  illustrate  the  practice  of  the  present  day ; 
but,  by  a  pretty  full  report  of  characteristic  examples,  selected  from 
more  than  one  thousand  cases  already  published  by  myself,  by  copious 
references  to  the  examples  recorded  by  others,  and  by  a  careful  ex- 
clusion of  whatever  has  not  been  confirmed  by  experience  or  esta- 
blished by  dissection,  I  have  endeavored  to  make  this  treatise  useful 
both  to  the  student  and  practical  man,  and  a  reliable  exponent  of  the 
present  state  of  our  art  upon  those  subjects  of  which  it  treats. 

In  order  to  render  the  description  of  the  various  forms  of  apparatus 
employed  in  the  treatment  of  fractures  more  intelligible,  and  to  avoid 
the  necessity  of  lengthened  explanations,  a  large  number  of  illustra- 
tions have  been  introduced,  more,  perhaps,  than  might  be  thought 
necessary,  especially  as  in  several  instances  the  apparel  which  is 
figured  is  not  that  which  is  recommended  by  the  author.  It  is  believed, 
however,  that  by  a  study  of  the  principal  forms  of  approved  dressings, 
the  reader  will  be  better  prepared  for  the  exigencies  of  practice ;  and 
that  by  the  simultaneous  presentation  of  those  which  are  not  approved, 
he  will  be  saved  from  a  wasteful  expenditure  of  his  time,  in  the  con- 
trivance of  useless  apparatus.  It  is  not  in  the  discovery  and  multi- 
plication of  mechanical  expedients  that  the  surgeon  of  this  day 
declares  his  superiority,  so  much  as  in  the  skilful  and  judicious 
employment  of  those  which  are  already  invented. 

The  author  desires  to  acknowledge  his  indebtedness  to  very  many 
of  his  professional  brethren,  throughout  the  United  States,  for  the 
promptness  with  which  they  have  responded  from  time  to  time  to  his 
inquiries,  and  for  the  generosity  with  which  they  have  opened  their 
pathological  collections  and  placed  valuable  specimens  at  his  disposal. 

He  wishes  also  to  express  his  special  obligations  to  Dr.  J.  E. 
Lothrop,  of  this  city,  who  has  kindly  aided  him  in  revising  most  of 
the  proof  sheets  as  they  have  been  issued  from  the  press. 

FEANK  H.  HAMILTON. 

Buffalo,  N.  Y.,  December,  1859. 


CONTENTS. 


PART   I. 

FRACTURES. 
CHAPTER   I. 

PAGE 

General  Division  of  Fkactures    .......         35 

CHAPTER   II. 

General  Etiology  of  Fractures  .......         37 

CHAPTER   III. 

General  Semeiology  and  Diagnosis  ......         41 

CHAPTER   IV. 

Repair  of  Broken  Bones  ........         45 

CHAPTER   y. 

General  Treatment  of  Fractures  .         .  .  .  .  .  .51 

CHAPTER   yi. 

Delayed  Union  and  Non-Union  of  Broken  Bones  .  .  .  .68 

CHAPTER   yil. 

Bending,  Partial  Fractures,  and  Fissures  of  the  Long  Bones  .  .  .         77 

§  1.  Bending  of  the  Long  Bones        ......         77 

§  2.  Partial  fracture  of  the  Long  Bones        .  .  .  .  .81 

§  3.  Fissures  ........         90 

CHAPTER   yill. 

Fractures  OF  the  Nose      .  .  .  .  .  .  ,.  .96 

§  1.  Ossa  Nasi  ........         96 

§  2.  Fractures  and  Displacements  of  the  Septum  Narium   .  .  .       101 


VIU 


CONTENTS. 


CHAPTER   IX. 

Fractuees  of  the  Malar  Bone    .  .  .      •       . 

CHAPTER   X. 

Fractures  of  the  Upper  Maxillary  Bones 

CHAPTER    XI. 

Fractures  of  the  Zygomatic  Arch 

CHAPTER   XII. 

Fractures  of  the  Lower  Jaw      .... 


CHAPTER   XIII. 


Fractures  of  the  Hvoid  Bone 


CHAPTER   XIY. 

Fracture  of  the  Cartilages  of  the  Larynx 
§  1.  Thyroid  Cartilage 
§  2.  Thyroid  and  Cricoid  Cartilages 
§  3.  Cricoid  Cartilage 

CHAPTER   XY 

Fractures  of  the  Vertebrae 

§  1.  Fractures  of  the  Spinous  Processes 
§  2.  Fractures  of  the  Transverse  Process 
§  3.  Fractures  of  the  Vertebral  Arches 
§  4.  Fractures  of  the  Bodies  of  the  Vertebr 

1.  Fractures  of  the  Bodies  of  the  Lumbar  Vertebrae 

2.  Fractures  of  the  Bodies  of  the  Dorsal  Vertebrae 

3.  Fractures  of  the  Bodies  of  the  five  lower  Cervical  Vertebrae 
§  5.  Fractures  of  the  Axis  ...... 

§  6.  Fractures  of  the  Atlas  ..... 

§  7.  Fractures  of  the  first  two  Cervical  Vertebrae  (Atlas  and  Axis)  at  the 

same  time       ........ 


PAGE 

104 


108 


113 


116 


138 


143 
143 
143 
145 


147 
147 
149 
150 
155 
157 
159 
160 
164 
167 

167 


CHAPTER   XYI. 


Fractures  of  the  Sternum 


168 


CHAPTER   XYII. 

Fractures  of  the  Ribs  and  their  Cartilages     . 

§  1.   Fractures  of  the  Ribs    .... 
§  2.  Fractures  of  the  Cartilages  of  the  Ribs 

CHAPTER   XYII  I. 


173 
173 

178 


Fractures  of  the  Clavicle 


179 


CONTENTS. 


IX 


CHAPTER   XIX. 

FfiACTUEES  OF  THE  ScAPULA  .... 

§  1.   Fractures  of  the  Body  of  the  Scapula 
^  2.  Fractures  of  the  Neck  of  the  Scapula 
§  3.  Fractures  of  the  Acromion  Process 
§  4.  Fractures  of  the  Coracoid  Process 


PAGE 

204 
204 
208 
210 
212 


CHAPTER   XX. 

Fkactures  of  the  Humerus  .......  215 

§  1.  Fractures  of  the  Head  and  Anatomical  Neck  .  .  .  216 

§  2.  Fractures  through  the  Tubercles  .....  220 

§  3.  Longitudinal  Fractures  of  the  Head  and  Neck ;  or  splitting  off  of  the 

Greater  Tubercle         .......  221 

§  4.  Fractures  through  the  Surgical  Neck  (including  Separations  at  the 

Upper  Epiphysis)       .  .  .  .  .  .  .  223 

§  5.  Fractures  of  the  Shaft  below  the  Surgical  Neck,  and  above  the  Base 

of  the  Condyles  .......  235 

^  6.  Fractures  at  the  Base  of  the  Condyles  (including  Separations  of  the 

Lower  Epiphysis)       .......  244 

§  7.  Fracture  at  the  Base  of  the  Condyles,  complicated  with  Fracture  be- 
tween the  Condyles,  extending  into  the  Joint            .             .              .  252 
§  8.  Fractures  of  the  Internal  Epicondyle                ....  255 

§  9.  Fractures  of  the  External  Epicondyle  ....  259 

§  10.  Fractures  of  the  Internal  Condyle      .....  260 

§  11.  Fractures  of  the  External  Condyle     .....  262 


CHAPTER   XXI 


Fkactures  of  the  Radius 


266 


CHAPTER   XXII. 

Fractures  of  the  Ulna  ..... 
§  1.  Shaft  of  the  Ulna  .... 

§  2.  Coronoid  Process  of  the  Ulna 
§  3.  Fractures  of  the  Olecranon  Process 

CHAPTER   XXIII. 

Fractures  of  the  Radius  and  Ulna 


294 
294 
299 
308 


316 


CHAPTER   XXIY. 

Fractures  of  the  Carpal  Bones 


325 


CHAPTER   XXY, 

Fractures  of  the  Metacarpal  Bones 


326 


CHAPTER   XXYI. 


Fractures  of  the  Fingers 


329 


CONTENTS. 


CHAPTER   XXYIT. 

Fbactdkes  of  the  Pelvis,  and  Traumatic  Sepaeations  of  its  Symphyses 
§  1.  Pubes  . 
§  2.  IscMum 
§  3.  Ilium  . 
§  4.  Acetabulum 
§  5.  Sacrum 
§  6.  Coccyx 


page 
332 
332 
335 
337 
340 
346 
347 


CHAPTER    XXYIII. 

Fkactctres  of  the  Femuk  .......  348 

§  1.  Neck  of  the  Femur       .......  348 

(a.)  Neck  of  the  Femur  within  the  Capsule  .  .  .  349 

(6.)  Neck  of  the  Femur  without  the  Capsule  .  .  .  382 

(c.)  Fractures  of  the  Neck  partly  within  and  partly  without  the 

Capsule  .......  388 

§  2.  Fracture  through  the  Trochanter  Major  and  Base  of  the  Neck  of  the 

Femur  ........  389 

§  3.  Fracture  of  the  Epiphysis  of  the  Trochanter  Major    .  .  .  390 

§  4,  Fractures  of  the  Shaft  of  the  Femur  .....  392 

§  5.  Fractures  of  the  Condyles        ......  434 

(a.)  Fractures  of  the  External  Condyle       ....  434 

(6.)  Fractures  of  the  Internal  Condyle        ....  435 

(c.)  Fractures  between  the  Condyles  and  across  the  Base  .  436 


CHAPTER   XXIX. 


Fractures  op  the  Patella 


438 


CHAPTER   XXX. 


Fractures  of  the  Tibia 


449 


CHAPTER    XXXI, 


Fractures  of  the  Fibula 


453 


CHAPTER   XXXII. 

Fractures  of  the  Tibia  and  Fibula 

CHAPTER   XXXIII. 

Fractures  of  the  Tarsal  Bones 

CHAPTER   XXXIV. 

Fractures  op  the  Metatarsal  Bones    , . 


457 


477 


482 


CHAPTER   XXXY. 

Fractures  of  the  Phalanges  of  the  Toes 


483 


CONTEXTS. 


XI 


PAET   II. 


DISLOCATIOXS. 


CHAPTER   I. 


GrENEKAL  COXSIDEEATIOXS 

§  1.  General  Division  and  ^"omenclature 

§  2.  General  Predisposing  Causes 

§  3.  Direct  or  Exciting  Causes 

§  4.  General  Symptoms 

§  5.  Pathology 

§  6.  General  Prognosis 

§  7.  General  Treatment 


PAGE 

487 
487 
488 
489 
489 
491 
492 
492 


CHAPTEU   II. 

Dislocations  of  the  Lowek  Jaw 

§  1.  Double  or  Bilateral  Dislocations 
§  2.  Single  or  Unilateral  Dislocations 
§  3.  Conditions  of  the  Jaw  simulating  Luxations  . 

CHAPTER    III. 

Dislocations  of  the  Spine  .... 

§  1.  Dislocations  of  the  Lumhar  Vertebrae 
§  2.  Dislocations  of  the  Dorsal  Vertebrae     . 
§  3.  Dislocations  of  the  Six  Lower  Cervical  Vertebrae 
§  4.  Dislocations  of  the  Atlas 
§  5.  Dislocations  of  the  Head  upon  the  Atlas,  or  Occipito-Atloidean  Dis 
locations         ....... 


; 

495 

. 

500 

• 

500 

502 

503 

504 

507 

514 

515 


CHAPTER   IV. 

Dislocations  of  the  Ribs  .... 

§  1.  Dislocations  of  the  Ribs  from  the  Vertebrae     . 
§  2.  Dislocations  of  the  Ribs  from  the  Sternum 
§  3.  Dislocations  of  one  Cartilage  upon  another     . 


516 
516 
517 
518 


CHAPTER   Y. 

Dislocations  of  the  Clavicle      ..... 
§  1.  Dislocation  forwards  at  the  Sternal  End 
§  2.  Dislocation  of  the  Sternal  End  of  the  Clavicle  Upwards 
§  3.  Dislocation  of  the  Sternal  End  of  the  Clavicle  Backwards 
§  4.  Dislocation  of  the  Acromial  End  of  the  Clavicle  Upwards 
§  5.  Dislocation  of  the  Acromial  End  of  the  Clavicle  Downwards 
§  6.  Dislocation  of  the  Acromial  End  of  the  Clavicle  under  the  Coracoid 
Process  ...  .  .  .  . 


518 
519 
523 

524 
526 

531 

532 


Xn  CONTENTS. 


CHAPTER    yi. 

PAGE 

Dislocations  of  the  Shoulder  (Humerus  at  its  Upper  Extremity)        .             .  533 

§  1.  Dislocation  of  the  Shoulder  Downwards  (Subglenoid)             .             .  533 

Dislocation,  with  Fracture  of  the  Humerus  near  its  Upper  End       .  558 

§  2.  Dislocation  of  the  Humerus  Forwards  (Subcoracoid  and  Subclavicular)  559 

§  3.  Dislocation  of  the  Humerus  Backwards  (Subspinous)            .             .  564 
§  4.  Partial  Dislocations  of  the  Humerus   .             .             .             •             .567 

CHAPTER   VII. 

Dislocations  of  the  Head  of  the  Radius             .....  570 

§  1.  Dislocation  of  the  Head  of  the  Radius  Forwards        .             .             .  570 

§  2.  Dislocation  of  the  Head  of  the  Radius  Backwards      .             .             .  575 

§  3.  Dislocation  of  the  Head  of  the  Radius  Outwards        .             .             .  577 

CHAPTER   YIII. 

Dislocations  of  the  Upper  End  of  the  Ulna  Backwards           .             .             .  578 

CHAPTER   IX. 

Dislocations  of  the  Radius  and  Ulna  (Forearm  at  the  Elbow-Joint)              .  579 

§  1.  Dislocations  of  the  Radius  and  Ulna  Backwards         .             .             .  579 

§  2.  .Dislocation  of  the  Radius  and  Ulna  Outwards  (to  the  Radial  Side)  588 

§  3.  Dislocation  of  the  Radius  and  Ulna  Inwards  (to  the  Ulnar  Side)      .  592 

§  4.  Dislocation  of  the  Radius  and  Ulna  Forwards             .             .             .  594 

CHAPTER   X. 

Dislocations  of  the  Wrist  (Radio-Carpal  Articulation)          .             .             .  595 

§  1.  Dislocations  of  the  Carpal  Bones  Backwards               .             .             .  597 

§  2.  Dislocations  of  the  Carpal  Bones  Forwards      ....  600 

CHAPTER    XI. 

Dislocations  of  the  Lower  End  of  the  Ulna  (Inferior  Radio-Ulnar  Articu- 
lation)              .........  601 

§  1.  Dislocations  of  the  Lower  End  of  the  Ulna  Backwards           .             .  601 

§  2.  Dislocation  of  the  Lower  end  of  the  Ulna  Forwards  .             .             .  602 

CHAPTER   XII. 

Dislocations  op  the  Carpal  Bones  among  themselves    ....  603 

CHAPTER   XIII. 

Dislocation  of  the  Metacarpal  Bones  (at  the  Carpo-Metacarpal  Articula- 
tions)   ..........  605 

CHAPTER   XIY. 

Dislocations  of  the  First  Phalanges  of  the  Thumb  and  Fingers  (at  the 

Metacarpo-Phalangeal  Articulations)           .....  607 

§  1.  Dislocations  of  the  First  Phalanx  of  the  Thumb  Backwards  .             .  607 

§  2.  Dislocations  of  the  First  Phalanx  of  the  Thumb  Forwards    .             .  615 
§  3.  Dislocations  of  the  First  Phalanx  of  the  Fingers        .             .             .616 


CONTENTS. 


XUl 


CHAPTER   XY. 

PAGE 

Dislocations  of  the  Second  and  Third  Phalanges  of  the  Thumb  and  Fingees  617 


CHAPTER    XVI. 

Dislocations  of  the  Thigh  (Coxo-Femoeal)        .....  619 

§  1.  Dislocations  Upwards  and  Backwards  on  the  Dorsum  Ilii       .  .  621 

§  2.  Dislocations  Upwards  and  Backwards  into  the  Great  Ischiatic  Notch  644 

§  3.   Dislocations  Downwards  and  Forwards  into  the  Foramen  Thyroideum  649 

§  4.  Dislocations  Upwards  and  Forwards  npon  the  Pubes  .  .  653 

§  5.  Anomalous  Dislocations,  or  Dislocations  which  do  not  properly  belong 

to  either  of  the  four  principal  divisions  before  described  .  658 

1.  Dislocations  directly  Upwards      .....  658 

2.  Dislocations  Downwards  and  Backwards  upon  the  Posterior  Part 

of  the  Body  of  the  Ischium,  between  its  Tuberosity  and  its 

Spine      ........  659 

8.  Dislocations  Downwards  and  Backwards  into  the  Lesser  or  Lower 

Ischiatic  Notch  ......  660 

4.  Dislocations  directly  Downwards  ....  661 

5.  Dislocations  Forwards  into  the  Perineum  .  .  .  661 
§  6.  Ancient  Dislocations  of  the  Femur  .....  662 
§  7.  Partial  Dislocations  of  the  Femur  .....  665 
§  8.  Coxo- Femoral  Dislocations,  complicated  with  Fracture  of  the  Femur  666 


CHAPTER   XYII. 

Dislocations  of  the  Patella 

§  1.  Dislocations  of  the  Patella  Outwards 
§  2.  Dislocations  of  the  Patella  Inwards     . 
§  3.  Dislocations  of  the  Patella  upon  its  Axis 
§  4.  Dislocations  of  the  Patella  Upwards     . 


669 
669 
672 
672 
675 


CHAPTER   XYIII. 

Dislocations  of  the  Head  of  the  Tibia  . 

§  1.  Dislocations  of  the  Head  of  the  Tibia  Backwards 

§  2.  Dislocations  of  the  Head  of  the  Tibia  Forwards 

§  3.  Dislocations  of  the  Head  of  the  Tibia  Outwards 

§  4.  Dislocations  of  the  Head  of  the  Tibia  Inwards 

§  5.  Dislocations  of  the  Head  of  the  Tibia  Backwards  and  Outwards 

§  6.  Slipping  of  the  Semilunar  Fibro-Cartilages 


675 
676 
678 
679 
680 
681 
682 


CHAPTER   XIX. 

Dislocations  of  the  Lower  End  of  the  Tibia 

§  1.  Dislocations  of  the  Lower  End  of  the  Tibia  Inwards 
§  2.  Dislocations  of  the  Lower  End  of  the  Tibia  Outwards 
§  3.  Dislocations  of  the  Lower  End  of  the  Tibia  Forwards 
§  4.  Dislocations  of  the  Lower  End  of  the  Tibia  Backwards 


684 
685 
689 
691 
693 


XIV 


CONTENTS. 


CHAPTER   XX. 

Dislocations  of  the  Upper  Enb  of  the  Fibula  . 

§  1.  Dislocations  of  the  Upper  End  of  the  Fibula  Forwards 
§  2.  Dislocations  of  the  Upper  End  of  the  Fibula  Backwards 

CHAPTER   XXI. 

Dislocations  of  the  Inferiok  Peeoneo-Tibial  Articulation 

CHAPTER   XXII. 

Tarsal  Luxations  .  .  •  • 

§  1.  Dislocations  of  the  Astragalus 
§  2.  Astragalo-Calcaneo-Soaphoid  Dislocations 
§  3.  Dislocations  of  the  Calcaneum 
§  4.  Middle  Tarsal  Dislocations 
§  5.  Dislocations  of  the  Os  Cuboides 
§  6.  Dislocations  of  the  Os  Scaphoides 
§  7.  Dislocations  of  the  Cuneiform  Bones   . 

CHAPTER  XXIII. 

Dislocations  of  the  Metatarsal  Bones 

CHAPTER   XXIV. 

Dislocations  of  the  Phalanges  of  the  Toes 

CHAPTER   XXV. 

Compound  Dislocations  of  the  Long  Bones 

CHAPTER  XXVI. 

Congenital  Dislocations  .... 

§  1.  General  Observations  and  History 
§  2.  Etiology  ..... 

§  3.  Congenital  Dislocations  of  the  Inferior  Maxilla 
§  4.  Congenital  Dislocations  of  the  Spine   . 
§  5.  Congenital  Dislocations  of  the  Pelvic  Bones   . 
§  6.  Congenital  Dislocations  of  the  Sternum 
§  7.  Congenital  Dislocations  of  the  Clavicle 
§  8.  Congenital  Dislocations  of  the  Shoulder  (Upper  End  of  the  Humerus) 
§  9.  Congenital  Dislocations  of  the  Radius  and  Ulna  Backwards 
§  10.  Congenital  Dislocations  of  the  Head  of  the  Radius 
§  11.  Congenital  Dislocations  of  the  Wrist 
§  12.  Congenital  Dislocations  of  the  Fingers 
§  13.  Congenital  Dislocations  of  the  Hip     . 
§  14.  Congenital  Dislocations  of  the  Patella 
§  15.  Congenital  Dislocations  of  the  Knee 
§  16.  Congenital  Dislocations  of  the  Tarsal  Bones 
§  17.  Congenital  Dislocations  of  the  Toes  . 


page 
694 
694 
695 


696 


697 
697 
703 
704 
705 
706 
706 
706 


708 


710 


712 


727 
727 
728 
730 
733 
734 
734 
734 
735 
739 
739 
740 
740 
741 
747 
747 
749 
749 


LIST  OF  ILLUSTRATIONS. 


FRACTURES. 

FIG. 

1.  Longitudinal  and  oblique  fracture   . 

2.  Impacted  extra-capsular  fracture  of  neck  of  femur 

3.  Union  of  fracture  with  the  fragments  widely  separated 

4.  Fracture  united  with  an  oblique  callus 

5.  Application  of  the  roller,  by  circular  and  reversed  turns 

6.  Many-tailed  bandage  .... 

7.  Application  of  the  many-tailed  bandage 

8.  Bandage  of  Scultetus  .... 

9.  Wood  and  leather  splint        .... 

10.  Welch's  veneered  gutta-percha  dorsal  splint  for  forearm 

11.  Welch's  veneered  gutta-percha  palmar  splint  for  forearm 

12.  Starch  bandage  applied  for  a  broken  thigh  . 

13.  Suetin's  pliers  ..... 

14.  Opening  the  apparatus  with  Suetin's  pliers 

15.  Apparatus  immobile,  applied  over  a  compound  fracture 

16.  Clavicle,  united  by  ligamentous  bands 

17.  Physick's  first  case,  treated  by  seton — after  28  years 

18.  Dieflfenbach's  drill  for  ununited  fracture 

19.  Brainard's  perforator  for  ununited  fracture 

20.  Fergusson's  case  of  permanent  bending  without  fracture 

21.  Partial  fracture  of  the  femur  without  restoration  of  the  bone  to  its  natural 

form  .... 

22.  Partial  fracture  of  the  clavicle  without  spontaneous  restoration 

23.  Partial  fracture  after  union  is  consummated 

24.  Fracture  of  the  lower  jaw     . 

25.  Mutter's  clamp  for  fractured  jaw 

26.  Gibson's  bandage  for  a  fractured  jaw 

27.  Barton's  bandage  for  a  fractured  jaw 

28.  Four-tailed  bandage  or  sling  for  the  lower  j 

29.  Pasteboard  compress  for  the  chin     . 

30.  The  author's  apparatus  for  a  broken  jaw 

31.  Fracture  of  the  spinous  process 

32.  Fracture  of  the  vertebral  arches 

33.  Oblique  fracture  of  the  body  of  a  vertebra 

34.  Key's  case  of  fracture  of  the  first  lumbar  vertebra 

35.  Parker's  case  of  fracture  of  the  odontoid  process  of  the  axis 

36.  Complete  oblique  fracture,  near  the  middle  of  the  clavicle 

37.  Fracture  of  the  clavicle  outside  of  the  trapezoid  ligament 

38.  Complete  oblique  fracture  of  the  clavicle  at  the  outer  end  of  the  inner 

two-thirds  .... 

39.  Comminuted  fracture  of  the  clavicle  united 

40.  Velpeau's  dressing  for  a  fractured  clavicle 


XVI 


LIST    OF    ILLUSTEATIONS. 


41.  Lonsdale's  dressing  for  a  fractured  clavicle 

42.  Keckerly's  apparatus  for  a  fractured  clavicle 

43.  Hunton's  apparatus  for  a  fractured  clavicle 

44.  Welch's  apparatus  for  a  fractured  clavicle,  applied — front 

45.  Wei  ell's  apparatus  for  a  fractured  clavicle — back  view 

46.  Figure-of-8  bandage,  for  a  broken  clavicle   . 

47.  Bartlett's  apparatus  for  a  fractured  clavicle 

48.  Fox's  apparatus  for  a  fractured  clavicle 

49.  The  author's  apparatus  for  a  fractured  clavicle 

50.  Fractures  of  the  body  and  acromion  process  of  the  scapula 

51.  Comminuted  fracture  of  the  glenoid  cavity 

52.  Fracture  of  the  neck  of  the  scapula 

53.  Fracture  of  the  coracoid  process 

54.  Fracture  at  the  anatomical  neck  of  the  humerus 

55.  56.  Pope's  specimen  of  supposed  fracture  at  the  anatomical  neck  of  the 

humerus,  and  reversion  of  the  head — front  and  side  views 
Separation  of  upper  epiphysis  of  humerus 
Welch's  shoulder  splint         ..... 
Oblique  fracture  of  the  shaft  of  the  humerus 
Dressings  applied  for  fracture  of  the  humerus,  with  the   sling  looped 

under  the  wrist     ...... 

Lonsdale's  apparatus  for  extension,  in  fractures  of  the  humerus 
Fracture  of  the  humerus  at  the  base  of  the  condyles 

63.  Fergusson's  dressing  for  fracture  of  the  humerus  near  the  elbow 

64.  Physick's  elbow  splints 

65.  Kirkbride's  elbow  splint 

66.  Day's  arm  and  forearm  splint 

67.  Rose's  arm  and  forearm  splint 

68.  Welch's  arm  and  forearm  splint 

69.  Bond's  elbow  splint  . 

70.  The  author's  elbow  splint 

71.  Fracture  at  the  base  of  the  condyles  of  the  humerus,  and  between  the 

condyles    .  •  . 

72.  Fracture  of  internal  epicondyle  of  the  humerus 

73.  Fracture  of  the  internal  condyle  of  the  humerus    . 

74.  Physick's  splint  for  fracture  of  the  condyles  of  the  humerus 

75.  Miitter's  specimen  of  fracture  of  the  neck  of  the  radius 

76.  Fracture  of  the  shaft  of  the  radius 

77.  Colles'  fracture — radius  near  its  lower  end 

78.  Bigelow's  case  of  comminuted  fracture  of  the  lower  end  of  the  radius 

79.  Welch's  "ulnar"  splint  for  fracture  of  the  radius  near  its  lower  end 

80.  Nelaton's  splint  for  fracture  of  the  radius  near  its  lower  end 

81.  Bond's  splint  for  fracture  of  the  lower  end  of  the  radius    . 

82.  Hay's  splint  for  fracture  of  the  lower  end  of  the  radius 

83.  E.  P.  Smith's  splint  for  fracture  of  the  lower  end  of  the  radius — front  view 

84.  Same  as  above — back  view  .... 

85.  Welch's  forearm  palmar  splint  .... 

86.  Welch's  forearm  dorsal  splint  .... 

87.  The  author's  splint  for  fracture  near  the  lower  end  of  the  radius 

88.  The  author's  dressing  for  a  fracture  of  the  radius  near  its  lower  end — 

complete    .... 

89.  Fracture  of  the  shaft  of  the  ulna 


289 
294 


LIST    OF    ILLUSTRATIONS. 


XVll 


FIG. 

90.  Fracture  of  the  coronoid  process  of  the  ulna 

91.  Fracture  of  the  olecranon  process  at  its  base 

92.  Olecranon  process  united  by  ligament        .... 

93.  Sir  Astley  Cooper's  method  of  dressing  a  fracture  of  the  olecranon  process 

94.  The  author's  splint  for  a  fracture  of  the  olecranon  process 

95.  The  same  applied    ....... 

96.  Fracture  of  the  radius  and  ulna  in  the  middle  third 

97.  Fracture  of  the  radius  and  ulna  in  the  lower  third 

98.  Radius  and  ulna  united  with  displacement 

99.  Clark's  case  of  comminuted  fracture  of  the  pelvis 

100.  Fracture  of  the  neck  of  the  femur,  within  the  capsule 

101.  Impacted  fracture  of  the  neck  of  the  femur,  within  the  capsule  . 

102.  Neck  of  unsound  femur — case  of  Mr.  S.,  reported  by  Mussey 

103.  The  same — vertical  section  ..... 

104.  Sound  femur  of  Mr.  S.         .....  . 

105.  Neck  of  unsound  femur  ;  case  of  Mr.  N.,  reported  by  Dr.  Mussey 

106.  Same  as  above — vertical  section     ..... 

107.  Sound  femur  of  Mr.  N.         .....  . 

108.  Neck  of  unsound  femur  ;  case  of  Mrs.  M.,  reported  by  Dr.  Mussey 

109.  The  same — vertical  section  ..... 

110.  Vertical  section  of  the  neck  of  the  femur,  capsule  and  acetabulum — case 

of  Mrs.  Wakelee   ....... 

111.  Section  of  the  head  and  neck  of  the  sound  femur  of  an  adult 

112.  Chronic  rheumatic  arthritis,  in  hip-joint    . 

113.  Crosby's  specimen  of  fracture  of  neck  of  femur  within  the  capsule — 

ununited    ........ 

114.  Mayo's  specimen  of  fracture  of  the  neck  of  the  femur  within  the  capsule 

united  by  ligament  ...... 

115.  Gibson's  Modification  of  Hagedom's  thigh  splints 

116.  Gibson's  splint  applied        ...... 

117.  118,  119.  Impacted,  estra-capsular  fracture 

120.  Fracture  of  the  neck  of  the  femur  .... 

121.  Extra-capsular  fracture  of  the  neck  of  the  femur — ununited. 

122.  Extra-capsular  fracture  of  the  neck  of  the  femur — with  excess  of  callus 

123.  The  same — vertical  section  ..... 

124.  Extra-capsular  fracture  of  the  neck  of  the  femur — united  with  irregular 

callus         ........ 

125.  Miller's  splint  for  extra-capsular  fractures 

126.  Sir  Astley  Cooper's  mode  of  treating  fractures  of  the  trochanter  major 

127.  Fracture  of  the  femur  at  the  base  of  the  condyles 

128.  Physick's  thigh  splint         ...... 

129.  Listen's  dressing  of  fractured  femur  with  a  straight  splint 

130.  Double  inclined  plane  employed  in  Middlesex  Hospital,  London  . 

131.  Amesbury's  double  inclined  plane  .... 

132.  Amesbury's  splint,  applied  ..... 

133.  Beyer's  thigh  splint,  applied  ..... 

134.  Nathan  R.  Smith's  suspending  thigh  splint,  or  double  inclined  plane 

135.  Welch's  thigh  apparatus     ...... 

136.  Nott's  double  inclined  plane  ..... 

137.  Surge's  fracture  bed  and  thigh  splint         .... 

138.  The  same  in  use      ....... 


XVlll 


LIST    OF    IL'LUSTEATIONS. 


FIG 

139. 
140. 
141. 

142. 
143. 
144. 
145. 
146. 
147. 
148. 
149. 
150. 
151. 
152. 
153. 
154. 
155. 
156. 

157. 
158. 
159. 
160. 
161. 
162. 

163. 
164, 
167. 
168. 
169. 
170. 
171. 
172. 
173. 
174. 
175. 
176. 
177. 

178. 
179. 

180. 

181. 
182. 
183. 

184. 
185. 


Neill's  straight  tliigli  splint,  for  extension  and  counter-extension 
Bowen's  thigh  splint  ...... 

Flagg's  thigh  apparatus — employed  in  the  Massachusetts  General  Hos 

pital.     Pelvic  belt  and  perineal  straps     . 
Same — foot  piece  and  screw 

Same — lateral  view  of  the  apparatus,  without  the  belt 
Same — front  view,  with  folded  sheet  laid  across    . 
Same — apparatus  applied,  front  view 
Same — apparatus  applied,  side  view 
Same — mode  of  applying  adhesive  plasters  to  leg 
Same — mode  of  making  extension  by  adhesive  plasters 
Same — perineal  band,  secured  with  a  padlock 
Sanborn's  thigh  splint         .... 
Dugas'  method  of  dressing  a  broken  thigh 
Same — mode  of  securing  the  extending  band  to  the  ankle 
Horner's  thigh  splint 
Joseph  Hartshorne's  thigh  splint    . 
Chapin's  thigh  apparatus    . 
Gilbert's  thigh  apparatus — mode  of  making  extension  and  counter-exten 

sion  with  adhesive  straps 
Same — applied  in  a  case  of  fracture  of  both  thighs 
Gilbert's  box  for  compound  fracture  of  the  thigh 
Lente's  long,  straight  thigh  splint,  modified  by  Tiemann 
Lente's  thigh  splint,  applied 

The  author's  single  straight  thigh  splint,  for  children  or  adults 
The  author's  single  straight  thigh  splint  for  children,  or  the  straight 

splint  in  its  simplest  and  elementary  form 
The  author's  double  straight  thigh  splint,  for  children  or  adults 
165,  166.  The  same — endless  screw;  front,  side,  and  end  views 
The  same — front  removed,  showing  the  interior 
Fracture  of  femur  just  below  trochanter  minor 
Jenk's  fracture  bed 

Daniel's  fracture  bed — descriptive  diagram 
The  same — complete 

The  same — in  use    .... 

Crosby's  specimen  of  fracture  of  the  external  condyle  of  the  femur 
Sir  Astley  Cooper's  case  of  fracture  of  the  external  condyle  of  the  femur 
Transverse  fracture  of  the  patella  .... 

Comminuted  fracture  of  the  patella  .... 

Transverse  fracture  of  the  patella — exhibiting  the  relations  of  the  mus 

cles  to  the  fracture  ...... 

Fragments  of  a  broken  patella  separated  by  flexion  of  the  knee 

Upper  fragment  of  a  broken  patella  drawn  up  very  much  by  the  action 

of  the  quadriceps  femoris 
Sanborn's  mode  of  dressing  a  fractured  patella — showing  the  application 

of  the  adhesive  plaster  band 
Same — applied  and  complete 
The  author's  mode  of  dressing  a  fractured  patella 
Wood's  apparatus  for  a  fractured  patella   . 
Dorsey's  patella  splint         ... 
Sir  Astley  Cooper's  method  for  broken  patella  by  circular  and  parallel 

tapes  ••....... 


447 


LIST   OF    ILLUSTEATIONS. 


XIX 


FIG.  PAGE 

186.  Sir  Astley  Cooper's  metliod  by  a  leather  band  and  counter-strap               .  448 

187.  Lonsdale's  apparatus  for  fractured  patella              ....  448 

188.  Fracture  of  tbe  fibula  near  its  lower  end   .....  453 

189.  Dupuytren's  splint  for  broken  fibula — modified      ....  455 

190.  Same — improperly  applied              .             .             .             .             .             .  .  456 

191.  Dupuytren's  splint,  as  originally  made  and  applied  by  bimself    •             .  456 

192.  Compound  and  comminuted  fracture  of  tbe  leg     ....  459 

193.  Long  splint  for  fracture  of  the  leg  in  Pott's  position           .             .             .  463 

194.  Hutchinson's  splint  for  extension  in  fractures  of  the  leg               .             .  467 

195.  Neill's  apparatus  for  fractures  of  the  leg  requiring  extension  and  counter- 

extension               ........  467 

196.  Neill's  apparatus  for  compound  fractures  of  the  leg           .             .             .  468 

197.  Crandall's  apparatus  for  fractures  of  the  leg  requiring  extension  and 

counter-extension — side  view       ......  468 

198.  Same.     Posterior  view  of  the  lower  section            .             .             .             .  469 

199.  Same.     Posterior  view  of  the  entire  apparatus      ....  469 

200.  Immovable  apparatus — applied  to  the  leg               ....  470 

201.  Liston's  double- inclined  plane,  applied  to  the  leg  in  a  case  of  compound 

fracture      .........  471 

202.  Welch's  jointed  apparatus  for  fractures  of  the  leg              .             .             .  471 
303.  Welch's  side  splints,  for  the  leg     .             .             .             .             .             .  472 

204.  Bauer's  wire  splints,  for  the  leg      ......  472 

205.  Swing  box,  for  fractures  of  the  leg              .....  473 

206.  Salter's  cradle,  for  fractures  of  the  leg       .....  473 

207.  Fracture  box  for  the  leg,  with  movable  sides          ....  474 

208.  209.  Malgaigne's  apparatus  for  certain  oblique  fractures  of  the  leg            474,  475 
210.  Apparatus  for  fracture  of  the  tuberosity  of  the  calcaneum            .             .  481 


DISLOCATIONS. 

211.  Clove  hitch  ........ 

212.  Compound  pulleys  and  ring  ..... 

213.  214.  Double  dislocation  of  the  inferior  maxilla 

215.  Ayres'  case  of  bilateral  dislocation  of  the  fifth  cervical  vertebra  . 

216.  Dislocation  of  the  sternal  end  of  the  clavicle,  forwards    . 

217.  Sir  Astley  Cooper's  apparatus  for  dislocated  clavicle 

218.  Dislocation  of  the  acromial  end  of  the  clavicle,  upwards  and  outwards 

219.  Mayor's  apparatus  for  dislocated  clavicle   .... 

220.  221.  Dislocation  of  the  shoulder  downwards  into  the  axilla — skeleton 

222.  New  socket,  in  an  ancient  luxation  of  the  shoulder  downwards    . 

223.  La  Mothe's  method  of  reducing  a  dislocation  of  the  shoulder — modified 

224.  Sir  Astley  Cooper's  method,  with  the  heel  in  the  axilla 

225.  Sir  Astley  Cooper's  method,  with  the  knee  in  the  axilla 

226.  Iron  knob  employed  by  Skey,  instead  of  the  heel 

227.  Skey's  method  in  dislocations  of  the  shoulder 

228.  Sir  Astley  Cooper's  method,  by  means  of  pulleys 

229.  230.  Subcoracoid  dislocation  of  the  humerus 

231.  Subcoracoid  dislocation       .... 

232.  Subspinous  dislocation  of  the  humerus 

233.  Displacement  of  the  long  head  of  the  biceps 

234.  Dislocation  of  the  head  of  the  radius  forwards — ana.tomical  relations 

235.  Dislocation  of  the  head  of  the  radius  forwards 


494 

494 
497,  498 
513 
519 
522 
527 
529 
535,  536 
542 
547 
548 
548 
549 
549 
550 
560 
561 
565 
568 
571 
572 


XX 


LIST    OF    ILLUSTRATIONS. 


Fia.  PAGE 

236.  Dislocation  of  the  head  of  the  radius  backwards  .             .             .  .577 

237.  Dislocation  of  the  upper  end  of  the  ulna  backwards         .             .  .         579 

238.  Dislocation  of  the  radius  and  ulna  backwards       •             .             .  .580 

239.  Sir  Astley  Cooper's  method  in  dislocation  of  the  radius  and  ulna  backwards         584 

240.  Most  frequent  form  of  incomplete  outward  dislocation  of  the  forearm  .         588 

241.  Most  frequent  form  of  incomplete  inward  dislocation  of  the  forearm  .         592 

242.  243.  Dislocation  of  the  carpal  bones  backwards      .             .             .  598,  599 
244,  245.  Dislocation  of  the  carpal  bones  forwards — skeleton   .             .  .         600 

246.  Dislocation  of  the  first  phalanx  of  the  thumb  backwards 

247.  Clove  hitch  ........ 

24:6.  Sir  Astley  Cooper's  method  of  reducing  dislocations  of  the  thumb  by  the 

pulleys       ......... 

249,  250.  Levis's  instrument  for  reduction  of  the  phalanges 

251.  Indian  "puzzle" — employed  in  the  reduction  of  dislocations  of  small  joints 

252.  Backward  dislocation  of  the  first  phalanx  of  the  index  finger — reduction 

by  extension  ........ 

253.  Dislocation  of  the  second  phalanx  backwards        .... 

254.  Dislocation  of  the  second  phalanx  forwards  .... 

255.  256.  Dislocation  of  the  femur  upon  the  dorsum  ilii  .  .  622,  624 

257.  Nathan  Smith's  method  of  reduction  of  a  dislocation  of  the  head  of  the 

femur  upon  the  dorsum  ilii,  by  manipulation 

258.  Hippocrates'  mode  of  reducing  dislocations  of  the  hip  by  manipulation 

259.  Reduction  of  a  dislocation  upon  the  dorsum  ilii  by  pulleys 

260.  Reduction  of  a  dislocation  upon  the  dorsum  ilii  by  a  twisted  rope 

261.  Jarvis's  adjuster — applied  in  dislocation  of  the  hip 

262.  Bloxham's  dislocation  tourniquet — applied  for  reduction  of  a  dislocation 

of  the  femur  upon  the  pubes        ...... 

263.  Reduction  of  a  dislocation  of  the  femur  upon  the  dorsum  ilii,  by  pulleys 

264.  265.  Dislocation  of  the  femur  upwards  and  backwards  into  the  great 

ischiatic  notch       .......  644,  645 

266.  Reduction  of  a  dislocation  into  the  great  ischiatic  notch,  by  pulleys        .         648 

267,  268.  Dislocation  of  the  femur  downwards  and  forwards  into  the  foramen 

thyroideum  ........         650 

269.  Sir  Astley  Cooper's  mode  of  reducing  recent  luxations  of  the  femur  into 

the  foramen  thyroideum  .......  652 

270.  Specimen  of  dislocation  upon  the  pubes,  in  St.  Thomas's  Hospital  .  654 

271.  Dislocation  upwards  and  forwards  upon  the  pubes  .  .  .  655 

272.  Reduction  of  dislocation  upon  the  pubes,  by  extension     .  .  .  657 

273.  Dislocation  of  the  patella  outwards  .....  670 

274.  Dislocation  of  the  patella  inwards  .  .  .  .  .  672 

275.  Dislocation  of  the  head  of  the  tibia  backwards     ....  676 

276.  Dislocation  of  the  head  of  the  tibia  forwards         ....  678 

277.  Subluxation  of  the  head  of  the  tibia  outwards      ....  680 

278.  Subluxation  of  the  head  of  the  tibia  inwards        ....  681 

279.  280.  Dislocation  of  the  lower  end  of  the  tibia  inwards      .  .  685,  686 

281.  Reduction  of  a  dislocation  of  the  ankle  by  pulleys  .  .  .         687 

282.  Dislocation  of  the  lower  end  of  the  tibia  outwards  .  .  .         690 

283.  284.  Dislocations  of  the  lower  end  of  the  tibia  forwards   .  .  .         691 
285,  286.  Dislocation  of  the  lower  end  of  the  tibia  forwards     .             .             .         694 

287.  Dislocation  of  the  astragalus  outwards — anatomical  relations      .  .         697 

288.  Simple  dislocation  of  the  astragalus  outwards       ....         698 

289.  Compound  dislocation  of  the  astragalus  inwards  ....         698 


608 
610 

611 
613 
614 

616 
618 
618 


630 
632 
634 
634 
635 

636 
642 


PART    I. 


FRACTURES. 


FRACTURES. 


CHAPTER    I. 

GENEEAL   DIYISION    OF   FEACTUEES. 

Feactures  are  divided  into  Complete  and  Incomplete,  Simple, 
Comminuted,  Compound,  and  Complicated, 

A  "  Complete"  fracture  is  one  in  which  the  line  of  division  com- 
pletely traverses  the  bone. 

An  "  Incomplete"  fracture  implies  only  a  partial  separation  of  the 
bone. 

A  "  Simple"  fracture  is  one  in  which  the  bone  is  broken  at  only 
one  point.  The  term  has  no  reference  to  the  question  of  complications, 
but  in  its  technical  meaning,  as  employed  by  both  English  and  Ameri- 
can surgeons,  it  has  reference  only  to  the  number  of  fragments  into 
which  the  bone  is  broken.  So  that  we  may,  without  a  paradox,  say 
of  a  fracture  that  it  is  both  simple  and  complicated,  or  simple  and 
compound.  It  would  be  more  correct,  perhaps,  to  substitute  the  word 
"  single"  for  "  simple,"  as  has  been  done  by  Malgaigne  and  some  other 
French  writers,  but  I  fear  that  to  American  surgeons  the  substitution 
would  be  rather  a  source  of  confusion  than  otherwise, 

A  "Comminuted"  fracture,  called  by  Malgaigne  "multiple,"  is  a 
fracture  in  which  the  bone  is  broken  at  more  than  one  point,  and  in 
which,  consequently,  the  bone  is  divided  into  more  than  two  frag- 
ments. It  also  is  used  in  a  technical  sense,  and  by  no  means  implies 
minute  division  or  comminution  of  the  fragments. 

A  "  Compound"  fracture  is  technically  one  in  which  there  exists 
also  an  external  wound  communicating  with  the  bone  at  the  point  of 
fracture.  It  may  be  either  partial  or  complete,  simple  or  comminuted, 
or  even  complicated,  while  at  the  same  time  it  is  also  compound. 

"  Complicated"  fractures  are  such  as  present  additional  complica- 
tions, or  complications  for  which  no  other  specific  term  has  been  in- 
vented. Thus  the  fracture  may  be  complicated  with  the  lesion  of  an 
important  bloodvessel  or  nerve,  or  with  great  contusion  or  laceration 
of  the  soft  parts,  with  a  dislocation,  or  with  fractures  of  other  bones, 
or  even  with  some  constitutional  fault. 

Fractures  are  also  divided  into  Transverse,  Oblique,  and  Longitu- 
dinal, according  as  the  direction  of  the  line  of  separation  is  at  a  right 


36 


GENEEAL    DIVISION    OF    FRAOTUEES. 


angle  with  the  axis  of  the  bone  at  the  point  of  fracture,  or  as  it  deviates 
more  or  less  from  this  direction.  But  a  fracture  is  called  transverse 
when  it  does  not  traverse  the  bone  precisely  at  a  right  angle ;  indeed, 
we  usually  apply  this  term  whenever  the  obliquity  is  only  moderate, 
not  exceeding,  perhaps,  fifteen  or  twenty  degrees,  or  when,  in  the 
examination  of  a  limb,  although  we  are  unable  to  detect  the  precise 
line  of  the  fracture,  we  ascertain  that,  without  being  impacted  or  ser- 
rated, the  ends  of  the  bones  continue  to  rest  upon  each  other,  or  being 
replaced,  do  not  spontaneously  become  displaced. 

Longitudinal  fractures  occur  generally  in  connection  with  oblique 
or  transverse  fractures ;  as  when  the  lower  end  of  the  femur  is  split 
vertically  into  the  socket,  and  the  shaft  of  the  bone  is  traversed  hori- 
zontally by  a  fracture  which  intercepts  the  vertical  or  longitudinal 
fracture.  The  fracture  of  a  condyle  or  of .  any  projection  from  the 
body  of  the  bone  is  called  longitudinal  if  the  direction  of  the  line  of 
fracture  is  parallel,  or  nearly  so,  to  the  axis  of  the  shaft. 


Fis.  1. 


Fig.  2. 


Longitudinal  and  oblique  fracture. 


Impacted  estra-capsular  fracture  of  neck  of  femur. 


A  "  Serrated"  fracture  is  one  in  which  the  opposite  surfaces  denti- 
culate, the  elevations  upon  one  fragment  being  reflected  by  corres- 
ponding depressions  upon  the  other. 

"  Impacted"  fractures  are  driven  into  each  other,  the  lamellated 
structure  of  one  fragment  penetrating  the  cancellous  structure  of  the 
other. 

The  French  writers  also  occasionally  speak  of  fractures  en  rave,  or 
radish-like,  and  of  fractures  en  hec  de  flute,  the  latter  being  so  called 
from  a  supposed  resemblance  to  the  mouth-piece  of  a  clarionet ;  but 
we  scarcely  see  the  necessity  of  multiplying  the  divisions  and  encum- 
bering our  nomenclature  by  these  fancied  resemblances.  For  all 
useful  purposes,  the  divisions  above  given  are  suflBcient. 

Epiphyseal  separations  we  do  not  hesitate  to  class  with  fractures, 
and  to  submit  them  to  the  same  rules  of  nomenclature. 


GENERAL    ETIOLOGY    OF    FRACTURES.  37 


CHAPTER    II. 

GENERAL   ETIOLOGY    OF    FRACTURES. 

The  causes  of  fractures  may  be  considered  as  predisposing  and 
exciting. 

Predisposing  Causes. — Partial  fractures,  witli  bending  of  the  bones, 
are  most  frequent  in  infancy  and  childhood ;  but  complete  fractures 
occur  most  often  during  manhood  ;  and  if  they  are  again  less  frequent 
in  old  age,  it  is  because  the  exciting  causes  are  less  operative,  since 
the  fragility  of  the  bones,  as  a  general  rule,  increases  with  the  age. 
It  will  be  noticed,  also,  that  somewhat  in  proportion  as  the  bone  is 
more  brittle,  its  fracture  will  be  more  nearly  transverse,  so  that  very 
old  persons  have  frequently  what  has  been  not  inaptly  termed  the 
"pipe-stem  fracture;"  but  we  must  except  from  this  rule  fractures 
occurring  in  children,  which  are  also  not  nnfrequently  transverse, 
often  denticulated  or  splintered,  and  but  rarely  oblique.  In  all  of  the 
intermediate  periods  of  life,  oblique  fractures  are  by  far  the  most 
common.  Females  are  less  liable  to  fractures  than  males,  except  in 
old  age,  when  the  law  seems,  in  general,  to  be  reversed.  As  to  the 
season  of  the  year,  it  has  been  generally  observed  by  surgical  writers, 
that  fractures  were  more  frequent  in  winter  than  in  summer,  and  an 
explanation  has  been  sought  for  in  the  greater  rigidity  of  the  muscles 
during  the  cold  weather,  and  the  greater  liability  to  falls  upon  the  ice 
and  frozen  ground.  Some  have  affirmed  that  the  bones  themselves 
were  more  brittle;  but  aside  from  the  improbability  of  this  last  expla- 
nation, it  is  really  a  matter  of  question  whether  fractures  are  actually 
any  more  frequent  in  the  winter  than  in  the  summer.  If,  on  the  one 
hand,  the  rigidity  of  the  muscles  and  falls  upon  slippery  walks  are 
active  causes  in  the  production  of  fractures  in  the  one  season,  on  the 
other  hand,  falls  from  buildings  and  accidents  from  a  great  variety  of 
similar  causes,  are  equally  active  agents  in  the  other. 

Mollities  ossium,  fragilitas  ossium,  rickets,  cancer,  tertiary  lues, 
scrofula,  gout,  scurvy,  mercurialization,  and,  in  short,  all  of  those 
diseases  dependent  upon  vicious  cachexias,  more  or  less  predispose  to 
the  occurrence  of  fractures.  Inflammation  of  the  periosteum,  also,  or 
of  the  bone  itself,  may  predispose  to  fracture.  It  is  said,  moreover, 
that  the  bones  of  persons  who  have  lain  a  long  time  in  bed  break 
easily. 

Exciting  Causes. — The  exciting,  determining,  or  immediate  causes 
of  fractures  are  of  two  kinds:  mechanical  violence  and  muscular  action. 

Of  these  two,  mechanical  or  external  violence  is  much  the  most 
frequent  cause ;  and  this  violence  may  operate  in  two  ways :  b}^  acting 


88  GENERAL    ETIOLOGY    OF    FEACTURES. 

directly  upon  the  bone  at  the  point  at  which  it  separates,  and  then  we 
say  the  fracture  is  "  direct,"  or  from  "  direct  violence ;"  or  by  acting 
upon  some  point  remote  from  the  seat  of  fracture,  and  then  we  say  the 
fracture  is  "  indirect,"  or  from  a  "  counter  stroke."  When  a  person 
falls  from  a  height,  alighting  upon  his  feet,  and  the  leg  or  thigh  is 
broken,  the  fracture  is  indirect;  so  also  if  the  bone  is  broken  by  flexion 
or  torsion.  Even  direct  pressure  upon  one  side  of  a  long  boue  in  a 
child  may  produce  a  partial  fracture  upon  the  opposite  side,  which  is 
properly  an  indirect  fracture ;  or  a  direct  blow  upon  the  trochanter 
major  may  occasion  a  counter  fracture  through  the  neck  of  the  femur. 

Fractures  from  muscular  action  occur  most  often  in  the  patella, 
calcaneum,  humerus,  femur,  tibia,  and  olecranon  process  of  the  ulna. 
These  accidents  imply  generally  some  conditions  of  the  bones  them- 
selves which  predispose  them  to  fracture ;  but  I  have  seen  one  example 
of  a  fracture  of  the  shaft  of  the  femur  in  a  large  and  perfectly  healthy 
man,  occasioned  by  a  twist  of  the  leg  in  rolling  tenpins.  I  have  also 
known  the  tibia  and  patella  to  break  from  natural  muscular  action  in 
persons  of  uncommon  vigor.  Fractures  sometimes  occur  in  the  violent 
contractions  of  the  muscles  during  convulsions,  and  where  no  abnormal 
condition  of  the  bones  could  be  assumed  to  exist.  Parker,  of  New 
York,  relates  a  case  of  fracture  of  the  humerus  in  a  negro  preacher, 
which  occurred  in  the  act  of  gesticulation;  also,  a  fracture  of  the 
clavicle  occasioned  by  striking  a  dog  with  a  whip ;  in  another  case 
the  humerus  was  broken  in  attempting  to  throw  a  peach;  but  the  most 
singular  case  of  all  was  a  fracture  of  the  humerus  caused  by  an  effort 
to  extract  a  tooth. ^ 

Nearly  all  of  the  cases  of  fractures  occasioned  by  muscular  contrac- 
tion seen  by  me  were  transverse,  or  nearly  so,  indicating,  perhaps, 
also,  the  existence  of  some  unusual  fragility ;  and  most  of  these  have 
been  unattended  with  shortening,  the  ends  of  the  bones  not  becoming 
completely  displaced  from  each  other.  The  example  of  fracture  of 
the  shaft  of  the  femur  just  mentioned,  was,  however,  an  exception. 
The  bone  shortened  to  the  extent  of  an  inch  or  more,  in  consequence 
of  overlapping,  and  in  this  position  it  has  finally  united. 

Intra-uterine  fractures  are  not  yet  fully  explained,  but  it  is  probable 
that  they,  like  extra-uterine  fractures,  may  be  ascribed  sometimes  to 
external  violence,  and  at  other  times  to  simple  muscular  contraction, 
both  perhaps  acting  upon  bones  already  somewhat  predisposed  by  a 
peculiar  constitutional  cachexy. 

Lawrence  Proudfoot,  of  New  York,  has  related  a  case  of  compound 
fracture  m  utero  occurring  in  the  practice  of  Dr.  Freeman,  which  was 
apparently  caused  by  external  violence.  Mrs.  F.,  sdl.  38,  always 
having  enjoyed  good  health,  during  the  sixth  month  of  gestation, 
while  attempting  to  pass  through  a  very  narrow  passage,  was  severely 
pressed  upon  the  abdomen,  and  immediately  experienced  a  severe  pain 
in  that  region,  accompanied  with  nausea  and  faintness.  The  following 
day,  uterine  hemorrhage  with  pain,  commenced ;  and  these  symptoms 
continued  at  intervals,  in  a  form  more  or  less  severe,  up  to  the  period 

'  Parker,  New  York  Journ.  Med.,  July,  1852,  p.  95. 


GENERAL    ETIOLOGY    OF    FRACTURES.  89 

of  her  delivery,  which  occurred  at  full  time,  and  was  perfectly  natural. 
At  birth,  the  right  foot  of  the  child,  a  female,  was  found  to  be  much 
distorted,  and  in  a  condition  of  valgus  with  equinus,  the  outer  side  of 
the  foot  being  laid  against  the  side  of  the  leg  above  the  external  mal- 
leolus. The  tibia,  also,  of  the  same  limb,  near  its  middle,  seemed  to 
have  been  the  seat  of  a  compound  fracture ;  the  two  ends  of  the  bone 
having  united  at  an  angle  slightly  salient  anteriorly,  and  the  skin 
presenting  over  the  point  of  fracture  an  old  cicatrix.  The  soft  tissues 
adjacent  were  considerably  thickened.  Seventeen  months  after  birth, 
when  the  child  was  seen  by  Drs.  Proudfoot,  Van  Buren,  and  Isaacs  of 
New  York,  the  foot,  although  much  improved  by  the  means  employed 
by  Dr.  Freeman,  was  still  considerably  deformed  in  consequence  of 
the  contraction  of  the  tendo-Achillis ;  on  cutting  which,  the  limb  was 
found  to  be  of  the  same  length  with  the  other.^ 

Dr.  Aristide  Rodrigue,  of  Hollidaysburg,  Pa.,  has  communicated  a 
case  of  fracture  with  dislocation,  which  he  ascribes  to  a  similar  cause. 
The  woman,  when  about  four  months  with  child,  fell  on  her  left  side, 
striking  upon  a  board,  and  hurting  herself  severely.  At  the  full  period 
she  was  delivered  of  a  well-grown  male  child.  Its  left  humerus  was 
found  to  be  dislocated  into  the  axilla,  and  both  the  radius  and  ulna  of 
the  same  limb  had  been  broken  through  their  lower  thirds,  but  were 
now  united  by  bony  callus  at  an  angle  of  about  45°,  and  slightly 
overlapped.  In  all  other  respects  the  child  was  perfect.  It  does  not 
appear  that  anything  was  done  to  the  fracture,  and  the  attempt  to 
reduce  the  humerus  was  unsuccessful.  Four  years  later  Dr.  R.  saw 
the  lad  and  found  him  strong  and  hearty,  the  dislocated  humerus 
having  grown  nearly  at  the  same  rate  with  the  opposite,  but  the 
forearm  remained  "  short  and  deformed  as  at  birth."  The  hand  was 
of  the  same  size  as  the  hand  of  the  sound  limb.^ 

Devergie  has  given  an  account  of  a  woman,  who,  when  seven 
months  with  child,  struck  her  abdomen  against  the  corner  of  a  table. 
Intense  pain  followed,  lasting  some  time.  She  went  her  full  period, 
however,  and  the  child  was  then  found  to  have  a  fracture  of  the  left 
clavicle,  the  fragments  being  overlapped  somewhat,  and  united  in 
this  position  by  a  firm  and  large  callus.^  A  woman  also  six  months 
gone  met  with  a  similar  accident,  and  at  the  full  time  she  gave  birth 
to  a  feeble  child,  having  in  one  leg  a  separation  of  the  shaft  of  the 
tibia  from  its  lower  epiphysis.  The  end  of  the  shaft  was  necrosed 
and  projected  through  a  wound  in  the  integument.  This  child  died 
on  the  thirteenth  day.^ 

Schubert  reports  the  case  of  a  female  delivered  before  her  term,  of 
twins,  one  of  whom  was  born  with  a  fracture  of  the  left  thigh  which 
had  occurred  in  utero ;  the  fractured  bone  had  pierced  the  flesh, 
through  which  it  projected  more  than  an  inch,  and  it  was  carious. 
The  mother  stated  that  about  six  weeks  before  the  accouchement, 
during  a  movement  of  the  foetus,  she  had  heard  a  noise  like  that 

'  Proudfoot,  New  York  Journ.  Med.,  Sept.  1846,  p.  199. 
^  Rodrigue,  Amer.  Jour.  Med.  Sci.,  Jan.  1854,  p.  272. 

*  Devergie,  Rev.  Med.,  1825. 

*  Malgaigne,  from  Arcbiv.  Gen.  de  Med.,  t.  xvi.  p.  288. 


40  GENEEAL    ETIOLOGY    OF    FEAOTURES. 

produced  by  breaking  a  stick,  and  from  that  moment  she  had  felt 
pricking  pains  in  her  bellj.^  It  is  probable  that  in  this  instance  the 
fracture  was  the  result  of  a  muscular  action,  although  it  is  possible 
that  it  was  occasioned  by  the  thigh  having  become  entangled  between 
the  legs  of  the  twin. 

In  many  other  examples  upon  record,  the  explanation  is  plainly 
enough  to  be  sought  for  in  the  abnormal  condition  of  the  bones. 
Monteggia  saw  in  a  newly  born  infant,  twelve  ununited  fractures. 
Chaussier,  who  has  published  a  memoir  upon  this  subject,  mentions 
two  very  extraordinary  cases,  in  one  of  which  the  child  presented 
forty-three  fractures,  and  in  the  other,  one  hundred  and  twelve.^  I 
myself  was  permitted  to  see,  on  the  29th  of  June,  1853,  with  Drs. 
Hawley  and  White,  of  this  city,  an  infant  only  four  days  old,  who  was 
born  at  the  full  time,  of  a  healthy  mother,  in  whom  nearly  all  of  the 
long  bones  -were  separated  and  movable  at  their  epiphyses,  the  motion 
being  generally  accompanied  with  a  distinct  crepitus.  The  bones 
were  also  much  enlarged  in  their  circumference ;  the  bones  of  the  fore- 
arm and  the  femur  were  greatly  curved ;  the  fontanelles  unusually 
open,  and  the  clavicles  were  entirely  wanting.  The  child  was  of  full 
size,  but  looked  feeble.  It  died  in  a  condition  of  marasmus  six  months 
after  birth ;  at  which  time  some  degree  of  union  had  taken  place  at 
several  of  the  points  of  separation,  the  limbs  having  been  supported 
constantly  with  pasteboard  splints  and  rollers, 

1  have  also  seen  one  example  of  complete  separation  of  the  tibia 
and  fibula  near  the  middle  of  the  leg,  which  I  was  disposed  to  regard 
as  defective  development  rather  than  as  an  instance  of  intra-uterine 
fracture;  and  a  gentleman  in  Michigan  has  recently  sent  me  an  ac- 
count of  another,  which  I  am  inclined  to  think  belongs  to  the  same 
class  of  deformities,  although  he  thought  it  might  be  a  case  of  intra- 
uterine fracture. 

Fractures  occurring  from  violence  inflicted  upon  the  child  by  the 
accoucheur,  or  from  contractions  of  the  neck  of  the  womb  while  the 
child  is  in  transitu^  are  more  common  occurrences,  and  do  not  require 
a  separate  consideration.  I  shall  mention  several  in  connection  with 
the  various  bones  in  which  they  have  taken  place;  among  which,  one 
of  the  most  interesting  is  that  published  by  Dr.  Jacob  H.  Vanderveer, 
of  Long  Branch,  N.  J.  The  mother  came  to  bed  on  the  18th  of  Janu- 
ary, 1847,  after  a  labor  of  more  than  twelve  hours.  It  was  a  foot 
presentation ;  the  child  weighed  fourteen  pounds,  and  was  perfectly 
healthy,  but  one  of  the  thighs  had  suffered  a  complete  fracture,  occa- 
sioned probably  by  the  strong  contractions  of  the  cervix  uteri.  With 
careful  splinting  and  bandaging,  the  bone  was  finally,  but  not  without 
some  difficulty,  kept  in  position  and  made  to  unite,  so  that  at  the  date 
of  the  report  one  would  not  discover  that  the  bone  had  been  broken, 
except  by  close  inspection.^ 

'  Amer.  Jour.  Med.  Sci.,May,  1828,  p.  223  ;  from  Zeitsch.  fiir  Staatsarz  von  Henke, 
7e.  Erg.  Heft.,  p.  311. 

2  Chaussier,  Bullet,  de  la  Faculte  de  Med.  de  Paris,  1813,  p.  301. 
^  Vanderveer,  Amer.  Journ.  Med.  Sci.,  May,  1847,  p.  378. 


GENEEAL    SEMEIOLOGY   AND    DIAGNOSIS.  41 


CHAPTER    III. 

GENERAL    SEMEIOLOGY   AND   DIAGNOSIS. 

Fracttjees  are  liable  to  be  confounded  witli  contusions,  and  with 
various  other  local  injuries,  but  most  often  with  dislocations;  and 
especially  when  the  fracture  has  taken  place  near  one  of  the  articula- 
tions, is  the  differential  diagnosis  sometimes  rendered  exceedingly 
dif&cult.  It  is  with  particular  reference,  therefore,  to  the  general 
points  of  distinction  between  fractures  and  dislocations,  that  I  now 
propose  to  speak.  The  special  signs  or  points  of  difference  which 
belong  to  each  individual  case,  will  be  considered  in  their  proper 
places. 

The  most  important  general,  or  common  signs  of  a  fracture — and  by 
"  common"  signs  I  mean  those  which  are  common  to  most  fractures — 
are  crepitus,  mobility,  and  an  inability  on  the  part  of  the  fragments 
to  maintain  their  positions  when  reduced;  indeed,  in  many  cases,  this 
constantly  recurring  displacement  is  due  to  the  fact  that  the  surgeon 
is  unable  to  accomplish  a  complete  reduction.  While  on  the  other 
hand,  dislocations  are  almost  as  uniformly  characterized  by  the  absence 
of  crepitus,  by  preternatural  immobility,  and  by  the  fact  that  when 
reduced  the  bones  do  not  usually  require  support  to  retain  them  in 
place,  or  indeed  we  may  say,  by  the  fact  that  they  are  generally  re- 
ducible. 

Let  us  study  these  phenomena  a  little  more  in  detail. 

Crepitus,  occasioned  by  the  chafing  of  the  broken  surfaces  upon 
each  other,  'when  actually  present,  is  almost  positive  evidence  of  the 
existence  of  a  fracture.  It  is  possible,  however,  to  confound  the  chaf- 
ing of  engorged  tendinous  sheaths,  or  of  inflamed  joints  upon  which 
fibrinous  effusions  have  occurred,  or  of  emphysema  even,  for  the  true 
crepitus  of  a  fracture ;  but  to  the  experienced  ear  and  well  practised 
touch  these  sensations  are  seldom  a  source  of  error.  The  one  is  rough, 
crackling,  or  even  clicking  sometimes,  while  the  other  is  more  sub- 
dued, and  imparts  a  more  uniform  sensation  to  the  hand,  and  but 
rarely  conveys  an  actual  sound,  unless  the  ear  is  directly  applied  or 
the  stethoscope  is  employed.  It  is  only  when  the  crepitus  is  trans- 
mitted obscurely  through  a  great  mass  of  soft  tissues,  or  sufficient 
time  has  elapsed  for  the  ends  of  the  fragments  to  become  softened  by 
inflammation,  and  partially  covered  with  a  plastic  material,  or  when 
indeed  a  dislocation  is  actually  coincident  with  the  fracture,  that  the 
surgeon  is  left  in  doubt.  Occasionally,  also,  the  existence  of  caries  or 
of  necrosis,  in  connection  with  a  dislocation,  might  lead  to  the  sup- 
position of  a  fracture;  but  the  history  of  the  case,  aside  from  the 
remaining  common  signs,  and  the  special  symptoms  hereafter  to  be 
enumerated,  would  prevent  any  possibility  of  error. 


42  GENEKAL    SEMEIOLOGT   AND    DIAGNOSIS. 

It  must  not  be  forgotten,  moreover,  that  a  fracture  at  one  point 
may  transmit  tbe  sensation  of  crepitus  distinctly  enough,  but  in  such 
a  direction,  owing  to  the  relations  of  other  bones  to  the  one  broken, 
as  to  mislead  the  surgeon,  and  induce  him  to  locate  the  fracture  in  the 
wrong  bone.  Several  examples  of  this  species  of  deception  I  shall 
hereafter  have  occasion  to  mention. 

Valuable  and  important  as  is  crepitus  in  its  relations  to  differential 
diagnosis,  unfortunately  it  is  not  always  present,  and  for  reasons 
which  must  be  plainly  stated.  First;  we  cannot,  in  a  pretty  large 
proportion  of  cases,  bring  the  broken  ends  again  into  apposition. 
Whatever  mere  theorists  may  say  to  the  contrary,  and  notwithstand- 
ing surgeons  up  to  this  time  have  rarely  ventured  to  allude  to  this 
subject,  the  fact  is  so  that  we  do  not  usually  "set"  broken  bones.  We 
do  not,  even  at  the  first,  bring  them  into  complete  apposition,  unless  it 
is  as  the  exception.  I  speak  of  bones  once  completely  displaced  by 
overlapping,  and  these  constitute  the  majority  of  examples  which 
come  under  the  surgeon's  observation.  Second;  in  transverse  frac- 
tures of  the  patella,  and  in  fractures  of  the  olecranon  and  coronoid 
process  of  the  ulna,  of  the  coracoid  and  acromion  process  of  the 
scapula,  and  in  all  similar  detachments  of  processes  and  apophyses, 
the  action  of  the  muscles  by  displacing  the  fragments  prevents  crepitus 
from  being  readily  produced.  Third ;  in  a  few  cases,  such  as  certain 
fractures  of  the  neck  of  the  femur,  of  the  neck  and  head  of  the  humerus, 
&c.,  the  broken  ends  are  impacted,  or  so  driven  into  each  other  as  to 
forbid  the  production  of  motion  and  crepitus  ;  or  they  may  be  simply 
denticulated,  and  the  consequences,  so  far  as  crepitus  is  concerned, 
will  be  the  same. 

Finally,  in  very  many  incomplete  fractures,  crepitus  does  not  exist, 
and  even  when  it  is  present  the  sensation  is  feeble,  or  very  much 
modified,  sometimes  resembling  the  chafing  of  lymph,  and  at  other 
times  giving  only  a  faint  and  single  click. 

Preternatural  mobility,  less  valuable  as  a  means  of  diagnosis  than 
crepitus,  is  nevertheless  more  constantly  present,  being  never  absent, 
in  some  degree,  in  all  complete,  non-impacted,  and  non-denticulated 
fractures ;  but  its  presence  does  not,  like  crepitus,  render  the  existence 
of  a  fracture  quite  certain.  Whenever  the  bony  lesion  takes  place  in 
the  vicinity  of  a  joint,  it  may  be  difficult  or  impossible  to  determine 
whether  the  mobility  of  the  limb  is  due  to  motion  in  the  joint  or  to 
motion  at  the  supposed  seat  of  fracture.  While,  on  the  other  hand, 
the  preternatural  immobility  so  generally  observed  in  dislocations, 
may  give  place  to  preternatural  mobility,  as  when  the  ligaments  and 
tendons  surrounding  the  joint  are  extensively  torn,  or  the  system  itself 
is  laboring  under  the  shock  of  the  accident,  or  when  from  any  other 
cause  there  exists  great  general  prostration. 

As  to  the  third  common  sign  mentioned,  namely,  that  in  the  case 
of  fractures  the  bones  do  not  generally  support  themselves,  but  de- 
mand for  this  purpose  the  interposition  of  splints,  bandages,  and  even 
of  extending  and  counter-extending  forces,  its  authority  rests  upon 
the  same  evidence  as  does  the  assertion  already  made  that  bones  once 
separated  entirely,  cannot  generally  be  "  set,"  that  is,  placed  again  end 


GENEEAL    SEMEIOLOGY    AND    DIAGNOSIS.  43 

to  end  in  such  a  manner  as  to  be  made  effectually  to  support  each 
other.  It  rests  upon  the  evidence  of  my  own  personal  experience ;  to 
which  I  am  permitted  to  add,  also,  the  personal  experience  of  Mal- 
gaigne,  who,  with  a  frankness  which  does  him  great  credit,  and  which, 
I  am  sorry  to  say,  has  hitherto  found  few  imitators,  remarks :  "Second. 
That  overlapping  is  the  most  stubborn  of  all.  Here  I  will  add  a  dis- 
agreeable truth,  which  classical  authors  have  kept  too  much  out  of 
sight,  namely,  that  it  is  so  stubborn  that  in  an  immense  majority  of  cases 
the  efforts  of  art  are  unable  to  overcome  it."^  And  it  must  be  observed 
further,  that  if  we  shall  often  find  it  possible  to  bring  the  broken  sur- 
faces sufficiently  into  contact  to  develop  crepitus,  they  may  still  be 
unable  to  maintain  themselves  in  this  position,  owing  to  the  obliquity 
of  the  line  of  fracture. 

The  other  common  signs  of  fracture  may  be  briefly  stated.  Pain 
at  the  seat  of  fracture;  swelling;  ecchymosis ;  deformity,  produced  by 
either  an  angular,  transverse,  or  rotary  displacement  of  the  fragments, 
and  which  is  much  more  often  due  to  the  direction  and  force  of  the 
impulse  which  occasioned  the  fracture  than  to  the  action  of  the  mus- 
cles ;  separation  of  the  fragments,  as  in  fractures  of  the  patella  and 
olecranon  process;  and  inability  to  move  "the  limb,  a  phenomenon  due 
in  part  to  the  breaking  of  the  bony  lever  upon  which  the  muscles 
acted,  and  in  part  to  the  intense  pain  caused  by  any  such  attempts. 
This  latter  symptom  is,  however,  often  entirely  absent.  It  is  not 
generally  present  in  impacted  fractures,  in  serrated  and  partial  frac- 
tures, or  in  many  other  fractures  in  which  the  periosteum  has  not  yet 
completely  given  way. 

Yelpeau  was  the  first,  I  think,  to  call  attention  to  the  fact  that 
patients  with  broken  clavicles  could  very  generally  raise  the  arm 
above  the  shoulder  and  even  to  the  head,  and  I  have  repeatedly  veri- 
fied the  observation,  notwithstanding  the  separation  of  the  fragments 
has  been  complete,  and  the  overlapping  considerable.  In  fractures  of 
the  neck  of  the  femur  and  of  the  tibia  it  is  no  uncommon  thing  for  the 
patient  to  walk  some  distance  after  the  receipt  of  the  injury, 

I  cannot  dismiss  this  subject  without  calling  attention  to  the  neces- 
sity of  exercising  care  and  gentleness  as  well  as  skill  in  the  examina- 
tion of  broken  limbs.  Nothing,  in  my  opinion,  betrays  a  lack  of 
judgment  as  well  as  of  common  humanity  on  the  part  of  the  surgeon, 
so  much  as  a  rude  and  reckless  handling  of  a  limb  already  pricked 
and  goaded  into  spasms  by  the  sharp  points  of  a  broken  bone.  It  is 
not  enough  to  say  that  such  rough  manipulation  is  generally  unneces- 
sary, it  is  positively  mischievous,  provoking  the  muscles  to  more 
violent  contractions ;  increasing  the  displacement  which  already  exists, 
and  not  unfrequently  producing  a  complete  separation  of  impacted, 
denticulated,  transverse,  or  partial  fractures,  which  can  never  after- 
wards be  wholly  remedied ;  augmenting  the  pain  and  inflammation, 
and  not  unfrequently,  I  have  no  doubt,  determining  the  occurrence  of 
suppuration,  gangrene,  and  death. 

In  proceeding  to  establish  the  diagnosis  in  any  case,  the  surgeon 
should  sit  down  quietly  and  patiently  by  the  sufferer,  so  as  to  inspire 

aigne,  Traite  des  Fractures  et  des  Luxations,  Paris  ed.,  t.  i.  p.  102, 


44  GENERAL    SEMEIOLOGY   AND    DIAGNOSIS. 

in  him  from  the  first  a  confidence  that  he  is  not  to  be  hurt,  at  least 
unnecessarily.  He  ought  then  to  inquire  of  him  minutely  as  to  all 
the  circumstances  immediately  relating  to  the  accident,  in  order  that 
he  may  determine  as  nearly  as  possible  its  cause,  which  alone,  to  the 
experienced  surgeon,  often  affords  presumptive,  if  not  conclusive  evi- 
dence as  to  the  nature  and  precise  point  of  the  injury.  From  this,  he 
should  proceed  to  examine  the  disabled  limb  ;  removing  the  clothes 
with  the  utmost  care  by  cutting  them  away  rather  than  by  pulling ; 
and,  when  completely  exposed,  he  should  notice  with  his  eye  its  posi- 
tion, its  contour,  the  points  of  abrasion,  discoloration,  or  of  swelling; 
and  not  until  he  has  exhausted  all  these  sources  of  information,  ought 
the  surgeon  to  resort  to  the  harsher  means  of  touch  and  manipulation. 
Nor  will  his  sensations  guide  him  to  the  point  of  fracture  by  any  other 
method  so  accurately  as  when,  the  patient  being  composed  and  his 
muscles  at  rest,  he  moves  his  fingers  lightly  along  the  surface  of  the 
limb,  pressing  here  and  there  a  little  more  firmly,  according  as  a  trifling 
indentation  or  elevation  may  lead  him  to  suspect  this  or  that  to  be  the 
point  of  fracture.  If  the  skin  is  more  than  usually  tender,  a  few  drops 
of  sweet  oil  or  of  fresh  lard  laid  upon  its  surface,  or  even  moistening 
the  skin  with  tepid  water,  will  render  this  examination  less  painful, 
whilst  it  will  facilitate  the  diagnosis,  by  rendering  the  tactile  sensation 
somewhat  more  acute. 

The  limb,  in  case  of  a  supposed  fracture  of  a  long  bone,  may  now 
be  measured  with  a  tape  line,  and  compared  with  the  opposite  limb, 
having  first  marked  with  a  soft  pencil  or  with  ink  the  several  points 
from  which  the  measurements  are  to  be  made. 

Finally,  if  any  doubt  remains,  the  limb  must  be  firmly  but  steadily 
held  while  the  necessary  manipulations  are  performed,  for  the  purpose 
of  ascertaining  the  existence  of  mobility  and  of  crepitus.  Mobility  is 
most  easily  determined  by  giving  to  the  limb  a  lateral  motion,  but  in 
general,  crepitus  is  most  effectually  developed  by  gentle  rotation.  If 
the  place  of  fracture  is  already  pretty  well  declared  by  the  previous 
examinations,  the  surgeon  should  place  one  finger  over  the  suspected 
point,  during  this  manipulation,  by  which  means  the  crepitus  will  be 
more  certainly  recognized. 

I  do  not  often  find  it  necessary  to  resort  to  anaesthetics  for  the 
purpose  of  insuring  quietude  and  annihilating  pain  in  making  these 
examinations,  since  it  is  seldom  that  the  patient  need  to  be  much  dis- 
turbed ;  but  if  the  examination  is  not  satisfactory,  and  the  diagnosis 
is  important,  I  do  not  hesitate  to  render  the  patient  completely  in- 
sensible, after  which  the  questions  in  doubt  may  be  more  thoroughly 
investigated  and  perhaps  definitively  settled. 

It  is  scarcely  necessary  to  say  that  the  earlier  the  examination  is 
entered  upon,  the  more  readily  will  the  diagnosis  be  made  out;  and 
if,  unfortunately,  some  time  has  already  elapsed  before  the  patient  is 
seen  by  the  surgeon,  and  much  swelling  has  taken  place,  the  exami- 
nation is  still  not  to  be  omitted,  and  whatever  doubts  remain  we  must 
endeavor  to  remove  by  repeated  examinations  made  from  day  to  day 
until  the  subsidence  of  the  tumefaction  has  brought  the  surfaces  of  the 
bone  again  within  the  reach  of  our  observation. 


REPAIR    OF    BROKEN    BONES.  45 


CHAPTER    IV. 

REPAIR  OP  BROKEN  BOXES. 

It  is  not  my  intention  to  enter  very  fully  into  a  consiaeration  of  the 
process  of  repair  in  fractures,  preferring  to  leave  this  subject  where  it 
more  properly  belongs,  to  the  general  treatises  on  surgical  pathology. 
And  especially  am  I  disinclined  to  this  topic,  because  of  the  discrep- 
ancy of  opinion  which  has  all  along  existed  upon  many  of  the  points 
involved,  and  which  differences  still  continue  to  exist,  even  among 
the  best  informed  pathologists,  and  to  the  final  settlement  of  which  I 
confess  I  have  not  brought,  except  perhaps  in  relation  to  one  single 
point,  any  new  observations  or  labors. 

I  only  propose  to  state  very  briefly  a  few  practical,  and  I  trust  I 
may  now  say,  pretty  well  established  facts,  such  as  the  manner  or 
position  in  which  this  reparative  material,  whenever  it  is  employed, 
is  applied  to  the  broken  bones,  the  length  of  time  which  is  usually 
required  for  the  completion  of  the  process  of  repair,  and  the  causes 
which  may  impede  or  prevent  bony  union. 

If  I  think  it  necessary  to  say  anything  more  upon  this  subject,  it 
will  be  simply  to  announce  my  belief  that  the  reparative  material, 
consisting  originally  of  a  plastic  lymph,  is  poured  out  from  the  vessels 
of  the  medullary  membrane,  the  periosteum,  the  broken  ends  of  the 
bone,  and  more  or  less  from  all  of  the  lacerated  tissues  which  are 
immediately  adjacent  to  the  seat  of  fracture ;  that  after  a  period,  louger 
or  shorter,  this  lymph  becomes  organized,  and  begins  to  receive  from 
the  same  sources  particles  of  bony  matter,  through  which  the  con- 
solidation is  finally  effected ;  that  the  transition  from  the  original 
plastic  material  to  bone  is  almost  constantly  through  the  interposition 
of  a  fibrous  tissue,  rarely,  unless  in  the  case  of  children,  through  a 
cartilaginous  tissue,  and  sometimes  through  both  consentaneously  or 
consecutively  ;  that  in  a  few  fortunate  examples  bones  unite  directly 
or  immediately,  without  the  intervention  of  a  reparative  material,  and 
fiuall}^,  that  granulations,  or  inflammatory  exudations  become  trans- 
formed into  bone,  or  perhaps  we  are  only  authorized  to  say  that  they 
immediately  precede  ossification,  in  certain  cases  of  compound  frac- 
tures, or  of  fractures  in  which  the  process  of  inflammation  exceeds 
certain  limits. 

This  last  proposition,  in  reference  to  the  agency  of  granulations  in 
the  production  of  callus,  or  their  mutual  pathological  relations,  is  at 
the  present  more  in  debate  than  either  of  the  others;  but,  with  this 
exception,  it  will  be  seen  that  I  have  carefully  avoided  all  of  those 
points  upon  which  the  observations  and  opinions  of  pathologists  are 
still  greatly  at  variance. 


46  EEPAIR  OP  BROKEN  BONES. 

Dupuytren,  enlarging  upon  the  doctrines  taught  by  Galen,  Duhamel, 
Camper,  and  Haller,  declared  that  "  nature  never  accomplishes  the 
immediate  union  of  a  fracture  save  by  the  formation  of  two  successive 
deposits  of  callus ;"  one  of  which  is  derived  from  the  periosteum  and 
from  the  adjacent  tissues,  and  from  the  medulla ;  while  the  other, 
derived,  perhaps,  from  the  broken  extremities  of  the  bone  itself,  is 
found  at  a  later  period  directly  interposed  between  these  surfaces. 
The  material  or  callus  derived  from  the  tissues  outside  of  the  bone, 
and  which  Galen  compared  to  a  ferule,  but  which  Mr.  Paget  calls 
"  ensheathing,"  together  with  the  material  derived  from  the  medulla, 
compared  often  to  a  plug,  and  by  Mr.  Paget  named  "  interior"  callus, 
is  by  Dupuytren  spoken  of  as  the  "provisional,"  or  temporary  callus; 
by  which  the  fragments  are  supported,  and  maintained  in  contact  until 
the  permanent  callus  is  formed.  This  temporary  splint  is  completed, 
or  has  arrived  at  the  condition  of  bone  in  a  spongy  form  at  periods 
varying  from  twenty  to  sixty  days ;  but  it  does  not  assume  the  cha- 
racter of  compact  bone  until  a  period  varying  from  fifty  days  to  six 
months  have  elapsed ;  after  which  it  is  gradually  removed  by  absorp- 
tion. The  second  process,  by  which  the  ends  of  the  bone  are  defini- 
tively or  permanently  united,  commences  when  the  provisional  callus 
has  arrived  at  the  stage  of  spongy  bone,  and  is  not  completed  usually 
within  less  than  eight,  ten,  or  twelve  months,  "when,"  says  Dupuytren, 
"  it  acquires  a  solidity  greater  than  the  original  bone." 

While  it  is  certain  that  this  eminent  surgeon  and  most  accurate 
observer  has  described  faithfully  the  various  phenomena  which  usually 
accompany  the  repair  of  bones  in  those  animals  which  were  the  sub- 
jects of  his  experiments,  and  that  his  conclusions  have  a  certain  degree 
of  application  to  the  human  species,  it  is  equally  certain  that  he  erred 
in  assuming  that  in  man  simple  fractures  always  unite  by  this  double 
process ;  yet,  such  is  the  power  of  authority,  these  doctrines  were  ac- 
cepted from  the  first  without  hesitation  or  debate,  and  for  nearly  half 
a  century  they  have  occupied  the  minds  of  surgeons  to  the  almost 
complete  exclusion  of  every  other  theory.  Mr.  Stanley  was  amiong 
the  first  to  question  the  solidity  of  the  doctrines  of  Dupuytren,  but  it 
remained  for  Mr.  Paget  to  fully  expose  their  many  fallacies ;  nor  has 
Malgaigne,  although,  not  strictly  a  disciple  of  Paget,  failed  to  detect 
certain  of  these  errors. 

I  should  also  do  injustice  to  myself  were  I  not  to  mention  that  at 
the  very  moment  when  Mr.  Paget  was  making  his  observations  upon 
the  specimens  in  "  the  large  collection  of  fractures  in  the  museum  of 
the  University  College,"  I  was  myself  employed  in  similar  researches 
both  among  cabinet  specimens  and  in  the  hospitals  of  this  country  and 
of  Europe;  and  that  the  conclusions  to  which  I  had  arrived  were 
nearly  identical  with,  although  the  inferences  were  far  from  being  so 
complete  in  their  detail,  as  those  to  which  this  distinguished  patholo- 
gist was  himself  brought.^  I  do  not,  however,  wish  to  make  Mr.  Paget 
responsible  for  any  of  the  opinions  upon  this  subject  which  I  shall 

'  Paper  on  "  Provisional  Callus,"  by  Frank  H.  Hamilton.  Buffalo  Medical  Journal, 
Feb.  1853. 


EEPAIR    OF    BROKEISr    BONES.  47 

hereafter  express,  except  so  far  as  they  may  be  found  to  agree  with 
his  own  published  views.'' 

I  think  it  may  now  be  fairly  stated  that  the  repair  of  bones  by  the 
double  process  described  by  Dupuytren,  is,  in  man,  only  an  exception 
to  a  very  general  rule;  and  that  fractures  unite  by  the  following 
modes : — 

First.  Immediately,  or  in  the  same  manner  that  the  soft  tissues 
sometimes  unite,  by  the  direct  reunion  of  the  broken  surfaces,  and 
without  the  interposition  of  any  reparative  material.  This  happens 
not  unfrequently  in  the  spongy  bones,  and  in  the  extremities  or 
spongy  portions  of  the  long  bones,  especially  when  one  portion  of 
bone  is  driven  into  another  and  becomes  impacted ;  as  in  certain  frac- 
tures of  the  neck  of  the  humerus  or  of  the  femur. 

Second.  By  interposition  of  a  reparative  material  between  the  broken 
ends;  as  when  the  fragments  remain  in  exact  apposition,  but  imme- 
diate union  fails.  This  is  especially  apt  to  occur  in  superficial  bones, 
such  as  the  tibia ;  or  upon  those  sides  of  the  bone  which  are  most 
superficial.  It  is  not  an  unusual  circumstance  to  find  the  shaft  of  the 
tibia  during  the  process  of  union  presenting  no  exterior  callus  upon 
its  anterior  and  inner  surface,  whilst  the  posterior  and  outer  section  of 
its  circumference  is  covered  with  an  abundant  deposit.  In  other  cases, 
however,  of  fractures  of  the  shaft  as  well  as  of  the  epiphyses,  the  in- 
termediate callus  secures  a  prompt  union,  but  no  ensheathing  callus  is 
ever  formed. 

Third.  Bones  broken  and  not  separated,  unite  occasionally  by  the 
process  described  by  Dupuytren,  namely,  by  the  formation,  first,  of  an 
ensheathing  callus,  whilst  at  the  same  moment  the  cylindrical  cavity 
becomes  closed  by  a  spongy  plug  or  a  compact  septum  of  bone;  and 
second,  by  definitive  callus  deposited  between  the  broken  ends.  It  is 
probable  that  this  happens  generally  in  children,  and  it  is  a  common 
mode  of  union  in  the  ribs,  which  bones,  during  the  whole  progress  of 
the  case,  are  necessarily  kept  in  motion.  My  cabinet  furnishes  many 
illustrations  of  ensheathing  callus  in  ribs ;  and  also  a  few  in  fractures 
of  the  tibia  and  fibula. 

Fourth.  Under  similar  circumstances,  where  no  displacement  exists, 
the  fracture  may  unite  by  ensheathing  and  interior  callus  alone,  no  in- 
termediate callus  ever  being  formed  between  the  broken  ends;  in  which 
case  it  may  be  properly  said  that  the  bone  itself  has  never  united,  and 
the  ensheathing  callus  instead  of  being  provisional  is  permanent  or 
definitive.  This  was  essentially  the  doctrine  of  Galen,  Haller,  and 
Duhamel  before  Dupuytren  added  his  "fifth  period,"  or  the  formation 
of  definitive  callus ;  and  by  these  older  surgeons  it  was  held  to  be  of 
universal  application,  except  perhaps  in  the  case  of  children.  To  this 
doctrine  also  Malgaigne  has  returned — at  least  to  the  question  "Is 
there  always  a  definitive  callus,  or  complete  union  of  the  fragments?" 
he  has  made  this  laconic  reply:  "Galen  admitted  its  occurrence,  but 
only  in  young  subjects ;  it  has  been  obtained  in  animals,  where  there 
had  been  no  displacement.     I  would  willingly  believe  that  such  is 

'  Lectures  on  Surgical  Pathology,  by  James  Paget,  Phila.  ed.,  1854,  Chapter  XI. 


48 


EEPAIE  OF  BEOKEN  BONES. 


sometimes  the  case  in  human  adults ;  but  I  must  confess  I  have  seen 
onlj  the  instance  above  cited,  which  might  just  as  well  be  used  to 
prove  the  compact  ossification  of  the  provisional  callus."  He  accepts 
it,  therefore,  as  not  only  an  occasional  mode  of  union,  but  as  the  most 
common  mode ;  and  in  support  of  this  extreme  view  he  finds  that  the 
exterior  callus,  which  Dupuytren  called  provisional  or  temporary,  is 
actually  permanent  unless  removed  by  the  absorption  consequent  upon 
pressure. 

To  all  of  which  we  can  only  say  that  an  examination  of  five  or  six 
specimens  in  our  own  cabinet,  after  having  carefully  divided  them 
with  a  saw,  has  furnished  only  one  illustration  of  union  by  ensheath- 
ing  and  interior  callus  alone.  In  each  of  the  other  specimens  the 
union  was  completed  by  definitive  or  intermediate  callus.  We  cannot, 
therefore,  avoid  the  conclusion  that  Malgaigne  has  been  deceived  as  to 
the  relative  frequency  of  these  different  modes  of  union,  and  that  union 
without  intermediate  callus  is  exceptional. 

Fifth.  When  bones  are  broken  and  overlap,  they  may  unite  by  the 
interposition  of  a  callus  between  the  opposing  surfaces,  that  is,  by  an 


Fig.  4. 


Fracture  of  the  thigli  of  a  turkey ;  united  with  the  frag- 
ments widely  separated.  From  a  specimen  in  the  author's 
cabinet. 

intermediate  callus,  but  which  will  dif- 
fer from  that  described  as  the  second 
method,  inasmuch  as  the  new  material 
will  be  deposited  upon  the  sides  of  the 
fragments  and  not  upon  their  extre- 
mities. The  limb  being  kept  perfectly 
at  rest,  and  all  other  circumstances 
proving  favorable,  this  union  may 
take  place  without  any  excess  or  irre- 
gularity in  the  deposit.  The  surfaces 
will  unite  firmly  where  they  are  in 
actual  contact,  and  smooth  and  well- 
formed  buttresses  will  fill  up  all  the 
spaces  between  the  bones  where  they 
are  not  in  actual  contact  suificient  gene- 
rally to  give  the  requisite  strength  to 
this  new  bond  of  union.  This  mode 
of  union  will  be  completed  sometimes 
when  the  two  ends  of  the  bones  are 
separated  laterally  an  inch  or  more  from 
each  other,     I  have  in  my  collection 


Fracture  of  the  shaft  of  the  femur ;  united 
with  an  oblique  callus.  From  a  specimen 
in  the  author's  cabinet. 


REPAIR  OF  BROKEN  BOXES.  49 

the  bone  of  a  turkey's  thigh  thus  united  by  a  transverse  bony  shaft, 
although  separated  more  than  one  inch,  and  what  is  less  common,  I 
possess  also  a  specimen  of  the  human  adult  thigh  in  which  an  oblique 
shaft  of  solid  callus  has,  after  many  months,  and  while  no  splints 
were  employed,  bound  together  firmly  the  two  opposite  extremities 
of  the  broken  bone. 

Sixth,  the  fragments  being  overlapped  more  or  less,  and  suffering 
unusual  disturbance,  or  the  adjacent  tissues  having  been  much  torn, 
or  much  blood  being  effused  so  that  considerable  inflammation  is 
caused,  the  amount  of  callus  will  exceed  what  is  necessary  for  the 
complete  union  of  the  bones;  and  this  redundancy  may  be  deposited 
around  and  upon  the  broken  ends  of  the  bones,  or  anywhere  in  their 
immediate  vicinity,  in  layers,  or  in  masses  of  irregular  shape  and  size. 
Even  the  bones  which  are  not  broken,  but  which  are  near,  as  in  the 
case  of  the  fibula,  after  a  fracture  of  the  tibia,  may  become  inflamed, 
or  their  coveriogs  may  inflame,  and  they  may  also  contribute  to  the 
general  mass  of  bony  callus. 

Compound  fractures,  or  rather,  we  ought  to  say,  fractures  accompa- 
nied with  granulations  and  suppuration,  obey  no  uniform  law  of  repair, 
so  far  as  the  manner  and  position  of  the  deposit  is  concerned;  but 
they  come  together  finally  with  more  or  less  irregular  distributions  of 
ossified  matter,  according  to  the  varying  circumstances  of  imperfect 
coaptation,  mobility,  (fee,  in  which  they  may  chance  to  be  placed. 
Occasionally  the  amount  of  callus  is  less  than  occurs  in  simple  frac- 
tures, and  at  other  times  the  excess  is  very  great. 

In  short,  we  conclude  that  fractures  of  adult  human  bones,  whether 
placed  end  to  end  or  overlapped,  unite  most  naturally  and  most 
promptly  either  immediately  or  mediately,  and  in  the  same  manner 
that  soft  tissues  unite ;  that  is  to  say,  without  the  interposition  of  any 
reparative  material,  or  through  the  medium  of  an  intermediate,  per- 
manent callus;  and  that  all  deviations  from  these  simple  methods  are 
accidental,  or  the  result  of  disturbing  influences. 

That  was,  no  doubt,  a  beautiful  thought,  which  ascribed  the  formation 
of  provisional  callus  to  an  intelligent  efficient  cause,  which  in  this  man- 
ner sought  to  support  the  fragments  until  a  reunion  of  their  divided 
ends  was  accomplished ;  nor  would  the  beauty  of  the  conception  be 
marred  by  ascribing  to  it  a  more  limited  application,  and.  invoking  its 
interference  only  when  the  ordinary  resources  of  nature  had  failed. 
We  no  longer  hold  that  such  intelligent  interposition  is  necessary  in 
the  first  instance,  but  that  if  demanded  at  all  it  is  only  for  an  exigency; 
and  we  have  grave  doubts  whether  nature  ever  allows  any  inter- 
ference with  her  laws  even  in  an  exigency,  unless  by  the  substitution 
of  a  miracle.  Provisional  callus  is  just  as  much  the  necessary  result 
of  natural  laws,  as  is  definitive.  It  is  formed  because  in  that  condition 
of  the  parts  and  of  the  general  life  its  formation  was  inevitable. 
"Whether  useful  for  the  purposes  of  repair  or  not,  it  will  under  certain 
circumstances  exist.  In  the  repair  of  certain  fractures,  provisional 
callus,  it  is  conceded,  seldom  occurs.  Thus  it  is  with  the  cranium, 
the  acromion,  coracoid  and  olecranon  processes,  the  patella,  and  with 
all  those  portions  of  bones  which  are  immediately  invested  with  a 

4: 


50  REPAIK    OF    BROKEN    BOjSTES. 

synovial  capsule.  Will  it  be  affirmed  that  in  the  examples  just  named 
this  callus  is  not  formed  because  it  is  not  required  ?  To  us  it  seems  that 
nowhere  could  it  prove  more  useful,  since,  with  the  single  exception  ■ 
of  the  cranium,  it  is  in  these  very  cases  that  the  obstacles  to  a  reunion 
are  the  most  serious.  In  fractures  of  the  patella,  olecranon,  &c.,  the 
action  of  the  muscles  tends  constantly  and  powerfully  to  displace  the 
fragments,  and  gladly  would  the  surgeon  avail  himself  of  the  assist- 
ance of  a  temporary  callus,  but  it  is  rarely  present,  at  least  in  any 
useful  degree.  So  also  in  fractures  of  the  neck  of  the  femur  within 
the  capsule,  and  in  other  similar  cases,  we  cannot  say  that  temporary 
callus  would  not  be  advantageous  in  facilitating  the  retention  of  the 
fragments,  yet  the  "intelligent  efficient  agent"  neglects  to  furnish  it. 

The  only  satisfactory  reason  which,  as  we  think,  can  be  assigned 
for  the  absence  of  callus  in  these  cases,  is  found  in  the  doctrines 
we  now  advocate ;  that  is  to  say,  it  is  usually  absent  because  that 
amount  of  excitement  and  irritation  is  usually  absent  which  alone 
determines  its  formation.  In  the  case  of  the  olecranon,  patella,  &c., 
the  fragments  being  separated  from  each  other  by  muscular  action,  so 
that  no  painful  pinchings  or  chafings  occur,  and  their  rough  surfaces 
or  sharp  points  being  rather  drawn  away  from  than  protruded  into 
the  flesh,  no  sufficient  provocation  exists  for  the  production  of  inflam- 
mation and  efi:'usion.  Hence  the  failure  of  provisional  callus,  but 
wherever  the  fracture  occurs,  and  however  moderate  the  action,  de- 
finitive callus  does  not  fail ;  still  the  broken  surfaces  of  the  patella 
and  olecranon  are  softened,  and  smoothed,  and  covered  over  with  a 
new  matter,  which,  if  contact  could  have  been  secured  and  preserved, 
would  certainly  have  served  to  consolidate  and  repair  the  breach. 
The  natural  reparative  process  proceeds,  but  only  the  accidental  pro- 
cess is  omitted.  This  latter,  however,  is  seen  again  even  here,  when 
from  other  and  unusual  causes  a  sur-excitement  is  established. 

Temporary  callus  is  not  formed  upon  bones  invested  with  synovial 
membranes,  because  here,  too,  as  in  the  neck  of  the  femur,  there  are 
not  so  many  structures  lacerated  and  irritated,  and  the  supply  of  this 
effusion  must  be  the  less  not  only  in  proportion  to  the  less  intensity 
of  the  inflammation,  but  also  to  the  less  amount  of  structures  impli- 
cated. 

Possibly  other  and  more  satisfactory  reasons  may  be  assigned  why 
provisional  callus  is  not  formed  usually  when  the  neck  of  the  femur  is 
broken  within  the  capsule ;  but  we  certainly  can  never  admit  the 
common,  and  as  here  applied,  the  too  palpably  absurd  explanation, 
that  it  is  not  wanted.  It  is  wanted,  and  in  no  case  so  much  as  in  the 
one  now  supposed. 

Provisional  callus  has,  therefore,  no  final  purpose,  but  is  the  un- 
avoidable result  of  certain  abnormal  conditions.  It  still  occurs  every- 
where when  against  and  in  the  vicinity  of  the  bone  there  is  the 
requisite  lesion  and  action,  and  it  will  occur  as  certainly  when  there 
is  no  fracture  at  all,  but  only  a  caries,  a  necrosis,  or  a  simple  bony 
or  periosteal  inflammation;  and  whilst  it  is  doubtless  true  that  in  frac- 
tures it  sometimes  renders  valuable  aid  to  the  surgeon,  it  is  equally 
true  that  it  often  proves  a  source  of  hindrance. 


GEISTERAL    TREATMENT    OF    FRACTUEES.  51 

From  these  remarks  I  choose  to  except  fractures  occurring  in  chil- 
dren, in  relation  to  which  the  observations  are  not  yet  sufficiently 
numerous  to  determine  absolutely  the  laws  of  repair.  If,  however,  I 
was  to  venture  an  opinion  based  upon  a  few  examinations,  I  should 
say  that  in  children  we  may  accept  with  but  little  qualification  the 
doctrine  of  Dupuytren  as  already  explained. 

Dupuytren,  in  determining  the  limits  of  his  "  third"  period,  or  of 
that  in  which  a  provisional  callus  is  formed  of  sufficient  strength  to 
support  the  fragments,  has  given  what  has  been  usually  quoted  as  the 
natural  period  within  which  bones  may  be  said  to  be  united,  that  is, 
"from  the  twentieth  or  twenty-fifth  day,  to  the  thirtieth,  fortieth,  or 
sixtieth."  But  this  depends  so  much  upon  the  age  of  the  patient,  his 
general  condition  of  health,  the  condition  and  position  of  the  broken 
ends,  as  well  as  upon  the  bone  itself,  and  the  point  at  which  it  is 
broken,  with  many  other  circumstances,  that  it  would  be  unsafe  to 
establish  any  absolute  laws  in  reference  to  this  point. 

In  very  early  infancy,  union  is  accomplished  in  half  the  time  re- 
quired in  adult  life,  and  it  is  generally  thought  to  be  still  more  re- 
tarded in  advanced  age,  but  Malgaigne  has  not  found  this  latter 
observation  confirmed  by  his  own  experience.  Various  coifetitational 
causes,  as  we  shall  hereafter  explain  more  fully,  retard  bony  union. 
Motion,  also,  sometimes  delays  consolidation :  fragments  which  are 
overlapped  do  not  unite  as  speedily  as  those  which  are  placed  end  to 
end,  and  other  complications  interfere  in  a  similar  manner,  such  as 
lesions  of  nerves,  of  bloodvessels,  comminution  of  the  bone,  &c.  It  is 
affirmed,  moreover,  that  in  general  the  bones  of  the  lower  extremities, 
independently  of  their  size,  unite  more  slowly  than  the  bones  of  the 
upper  extremities. 

For  a  more  complete  consideration  of  the  causes  which  retard  the 
union  of  bones,  I  beg  to  refer  the  reader  to  the  chapter  on  "  Delayed 
and  Non-Union  of  Bones." 


CHAPTER    V. 

GENERAL  TREATMENT  OF  FRACTURES, 

All  that  has  been  said  in  relation  to  the  propriety  of  handling  a 
broken  limb  gently  when  the  surgeon  is  examining  the  position  and 
character  of  the  fracture,  is  equally  applicable  to  the  lifting  and  trans- 
porting of  the  patient  to  his  bed,  to  the  removal  of  the  clothing,  and 
to  the  general  management  of  the  limb  before  it  is  dressed.  Eude  or 
awkward  manipulations,  by  which  needless  pain  is  inflicted,  are  not 
simply  acta  of  wanton  cruelty,  but  they  are  sources,  and  I  think  I  may 


52  GENERAL  TREATMENT  OP  FRACTURES. 

say  frequent  sources,  of  inflammation,  suppuration,  and  gangrene. 
Here,  as  in  all  the  subsequent  handlings,  everything  should  be  done 
slowly,  thoughtfully,  and  systematically.  Yet  it  is  difficult  to  state 
the  precise  manner  in  which  the  surgeon  ought  to  proceed.  Much 
will  depend  upon  the  circumstances  of  the  case,  something  upon  one's 
natural  tact,  and  upon  the  amount  of  experience,  but  more,  I  think, 
upon  natural  kindness  of  heart,  and  social  education.  The  man  of 
refinement  and  sensibility  will  know  instinctively  how  to  proceed, 
and  needs  no  instruction.  They  who  lack  these  qualities  can  never 
learn,  and  it  would  be  quite  useless  to  undertake  to  teach  them.  I 
sincerely  wish  such  men  as  these  latter  would  find  some  more  suitable 
employment  than  the  practice  of  a  humane  art. 

Nearly  all  fractures  present  three  principal  indications  of  treatment, 
namely,  to  restore  the  fragments  to  place  as  completely  as  possible,  to 
maintain  them  in  place,  and  to  prevent  or  to  control  inflammation, 
spasms,  and  other  accidents. 

It  ought  to  be  regarded  as  a  rule,  liable  only  to  rare  exceptions, 
that  broken  bones  should  be  restored  to  place,  or  to  the  position  in 
which  we  hope  to  maintain  them,  as  soon  as  possible  after  the  occur- 
rence of  tUl  accident.  If  the  patient  is  seen  within  the  first  few  hours, 
or  before  much  swelling  has  taken  place,  we  scarcely  know  the  cir- 
cumstance which  would  warrant  an  omission  to  adjust  the  fragments 
either  end  to  end  or  side  by  side,  as  the  one  or  the  other  might  be 
found  to  be  practicable.  We  have  before  sufficiently  explained  the 
general  impossibility  of  again  restoring  to  place,  end  to  end,  and  fibre 
to  fibre,  "fragments  which  have  been  made  to  override.  We  are  there- 
fore in  no  danger  of  being  understood  to  say  that  bones  should  in  all 
cases  be  immediately  "set,"  in  the  popular  sense  of  this  term.  They 
ought  to  be  "  set,"  no  doubt,  if  this  can  be  accomplished  through  the 
application  of  a  prudent  amount  of  force ;  but  if  they  cannot  be  thus 
placed  end  to  end,  they  may  at  least  be  laid  in  such  a  manner  side  by 
side  as  to  restore,  in  some  measure,  the  natural  axis  of  the  limb,  and 
prevent  the  points  of  the  bone  from  pressing  unnecessarily  into  the 
flesh. 

Experience  has  indeed  furnished  us  with  four  or  five  very  good 
reasons  why  broken  bones  should  be  reduced  as  soon  as  possible. 
When  the  injury  is  recent,  the  muscles  offer  less  resistance ;  their 
resistance  being  increased  after  a  time  not  only  by  the  reaction  which 
ensues  upon  the  shock,  but  also  by  actual  adhesion  between  their 
fibres ;  effusions  distend  both  the  muscles  and  the  skin,  and  compel 
the  limb  to  shorten ;  the  constant  goading  of  the  flesh  by  the  sharp 
points  of  the  broken  bones  increases  the  muscular  contractions;  the 
patient  will  submit  readily  to  manipulation  and  extension  at  first,  but 
after  the  lapse  of  a  few  days,  it  is  very  seldom  that  he  will  permit  the 
limb  to  be  in  any  manner  disturbed,  even  if  he  is  assured  that  his 
refusal  entails  upon  him  a  great  deformity.  If  it  is  true  that  no  callus 
or  bony  structure  is  deposited  earlier  than  the  seventh  or  tenth  day, 
it  is  also  true  that  the  renewed  attempt  to  adjust  the  bones  at  this 
period,  by  chafing  and  tearing  again  the  tissues,  reduces  the  fracture, 
in  some  degree,  to  the  same  condition  in  which  it  was  at  the  first,  and, 


GENERAL    TREATilEXT    OF    FRACTURES. 


53 


consequently,  the  time  which  has  elapsed,  or,  at  least,  a  portion  of  it, 
may  be  regarded  as  lost. 

We  cannot,  therefore,  understand  the  argument  by  which  Bromfield, 
South,  and  a  few  other  surgeons  have  persuaded  themselves  that  re- 
duction should  never  be  attempted  before  the  third  or  fourth  day; 
nor,  indeed,  do  we  fully  appreciate  the  refinement  which  Malgaigne 
has  given  to  this  question  in  itself  so  simple.  To  affirm  that  we 
ought  not  to  reduce  the  bones  to  their  original  positions  during  the 
period  of  intense  inflammation,  or  of  great  swelling,  or  while  the 
muscles  are  acting  spasmodically,  is  only  to  affirm  that  we  may  not 
do  what  is  impossible;  and  the  attempt  to  do  which,  therefore,  can 
only  be  mischievous ;  but  to  authorize  their  restoration  to  a  better 
position,  by  such  manipulation,  extension,  and  lateral  support  as  they 
may  comfortably  bear,  is  warrantable  under  any  circumstances.  The 
practice  is  not  only  defensible  but  imperative,  and  we  do  not  think 
any  really  sound  and  practical  surgeon  ever  intended  to  teach  the 
contrary.    We  say  still,  if  bones  can  be  easily  reduced,  or  the  position 


Fis.  5. 


Fiar.  6. 


Many-tailed  bandage. 

of  the  fragments  improved  at  any 
moment  or  under  any  circum- 
stances, it  ought  to  be  done ;  and 
if  we  fail  in  accomplishing  all 
that  we  wish  to  do  in  the  first  in- 
stance, we  must  remain  incessantly 
watchful  to  seize  the  earliest  oppor- 
tunity which  presents,  to  complete 
the  adjustment.  No  doubt  our 
efforts  will  prove  fruitless  very 
much  in  proportion  to  the  amount 
of  swelling,  inflammation,  or  mus- 
cular spasm  which  exists,  and  also 
in  proportion  to  the  time  which 
has  elapsed,  but  this  will  not  ex- 
cuse us  for  omitting  to  do  all  which  the  circumstances  permit. 

It  has  been  the  practice  of  most  surgeons,  for  a  long  period,  to  cover 


Application  of  the 
versed  turns. 


'roller"  by  circular  and  re- 


54 


GENEEAL  TEEATMENT  OF  FEACTUEES. 


the  broken  limb  with  some  form  of  a  bandage  or  roller  before  apply- 
ing the  lateral  splints. 

Of  these  primary  dressings  there  are  two  principal  varieties :  first ; 
the  "roller,"  or  simple  bandage,  applied  to  the  limb  in  circular  and 
reversed  turns;  and,  second;  the  "many-tailed  bandage,"  consisting  of 
a  piece  of  muslin,  or  other  cloth,  torn  down  from  each  side  into  a 
suitable  number  of  strips,  leaving  the  centre,  which  is  to  be  applied 
to  the  back  of  the  limb,  entire. 


Fig.  8. 


Application  of  tlie  many-tailed  bandage. 


Bandage  of  Scultetus. 


A  modification  of  this  bandage  consists  of  a  number  of  separate 
strips,  so  laid  upon  one  another,  commencing  from  above,  as  that  each 
strip  shall  overlap  the  other  by  one-third  or  one-half  of  its  breadth. 
This  is  called  the  bandage  of  Scultetus,  and  it  possesses  one  advantage 
over  the  many-tailed  bandage  just  described,  especially  in  the  case  of 
compound  fractures,  in  the  faciiity  with  which  each  separate  piece 
may  be  removed  and  another  substituted.  Some  surgeons  prefer  to 
form  the  bandage  of  separate  strips,  and  having  overlaid  them  in  the 
manner  directed,  to  unite  them  again  into  one  by  running  a  thread 
through  the  whole  mass  along  the  centre. 

Whichever  of  these  several  varieties  of  strips  ace  employed,  the 
mode  of  applying  them  is  the  same.  They  are  folded  alternately 
around  the  limb,  being  made  to  overlap  and  cross  upon  each  other 
in  front,  and  only  the  last  strip  or  two  is  fastened  with  a  pin. 


GENERAL    TREATIEEXT    OF    FKACTURES.  55 

The  object  proposed  in  the  use  of  the  roller  or  of  the  many-tailed 
bandage  is  twofold:  first,  to  compress  and  support  the  muscles,  by 
which  their  tendency  to  contraction  is  in  some  measure  controlled ; 
and  second,  to  protect  the  limb  against  the  direct  pressure  of  the  side 
splints. 

A  moment's  consideration  will  convince  us  that  the  first  of  these 
objects  is  in  most  cases  fully  attained  by  the  lateral  splints  themselves, 
and  by  the  bandages  by  which  they  are  retained  in  place:  and  that 
the  second  can  be  as  well  accomplished  by  a  single  fold  of  cloth,  or  by 
the  compresses,  which  ought  generally,  even  when  the  roller  is  used, 
to  underlie  the  splints.  Nevertheless  we  should  hardl}^  feel  authorized 
to  reject  these  primary  dressings  solely  because  the  splints  and  com- 
presses furnish  a  convenient  substitute,  especially  since  we  are  com- 
pelled to  admit  that  they  are  occasionally  useful,  unless  objections  of  a 
more  serious  nature  could  be  brought  against  them.  Unfortunately 
this  latter  supposition  is  actually  true.  By  ligating  the  limb  com- 
pletely, leaving  no  point  of  the  tegumentary  surface  to  which  the 
pressure  is  not  applied,  they  too  often  occasion  congestions,  inflamma- 
tion and  gangrene.  It  is  not  until  lately  that  the  attention  of  surgeons 
has  been  sufficiently  called  to  this  subject ;  but  the  records  of  surgery 
are  to  day  filled  with  these  terrible  accidents,  formerly  attributed  to 
the  original  injury  or  to  the  splints  themselves,  but  now  understood 
to  be  plainly  traceable  to  the  too  common  employment  of  the  primary 
bandage.  The  roller  is  by  far  the  most  dangerous  dressing  of  the  two, 
since  it  does  not  yield  to  the  swelling  so  readily  as  the  bandage  of 
strips,  and  it  is  more  objectionable  also  on  account  of  the  inconve- 
nience of  applying  and  removing  it;  but  even  the  bandage  of  strips 
may  be  so  confined  as  to  produce  the  same  consequences,  as  I  have 
myself  seen  in  more  than  one  instance.  It  is  also  all  the  more  dan- 
gerous in  the  hands  of  the  inexperienced  surgeon,  because  he  feels 
a  confidence  that  it  will  not  cause  ligation. 

Except  in  rare  cases  and  for  especial  reasons,  which  we  shall  attempt 
to  indicate  in  their  appropriate  places,  we  cannot  recommend  the  em- 
ployment of  any  kind  of  bandages  next  to  the  skin. 

In  order  to  fulfil  the  second  indication,  namely,  to  maintain  the 
fragments  in  place,  we  employ  usually  what  are  called  short  or  side 
splints,  and  long  or  extending  splints. 

Side  splints  may  be  constructed  from  various  materials,  according  to 
the  size  and  circumstances  of  the  limb,  or  according  to  the  convenience 
of  the  surgeon ;  and  as  the  surgeon  cannot  be  expected  to  have  always 
on  hand,  at  the  bedside  of  the  patient,  such  splints  as  he  might  prefer 
to  use,  it  is  well  for  him  to  understand  how  to  avail  himself  of  such 
materials  as  may  be  within  his  reach,  in  order  that  he  may  make  the 
most  of  his  sometimes  imperfect  resources. 

Lead,  sheet  iron,  zinc,  and  other  metals  have  been  occasionally  em- 
ployed, but  especially  tin  and  copper,  which  possess  all  of  the  requisite 
firmness  and  malleability  to  allow  them  to  be  hammered  and  thus 
moulded  to  the  limb.  In  general,  however,  they  are  unnecessarily 
heavy,  and  demand  too  mach  labor  to  be  wrought  into  shape.  I  have 
sometimes   employed  tin  splints   perforated  with   large  fenestras  to 


66  GENERAL  TREATMENT  OF  ERACTURES. 

diminish  their  weight  and  increase  their  flexibility,  and  found  them 
to  answer  an  excellent  purpose. 

Iron  wire  splints,  made  from  wire  cloth  or  coarse  gauze,  was  first 
publicly  mentioned,  so  far  as  I  can  learn,  in  a  communication  to  the 
Memphis  Medical  Recorder^  made  by  Dr.  J.  C.  Nott,  of  Mobile ;  but  it 
has  been  brought  more  particularly  into  notice,  and  its  construction 
perfected  by  Louis  Bauer,  of  New  York.'  These  splints  are  moulded 
upon  "gypsum  or  wooden  casts,"  of  different  sizes,  and  surrounded  with 
a  stout  iron  wire  frame  in  order  to  give  them  the  requisite  degree  of 
firmness,  and  to  preserve  their  forms ;  after  which  they  are  tinned  by 
galvanism,  and  varnished,  to  prevent  them  from  becoming  rusted. 
When  applied.  Dr.  Bauer  recommends  that  they  shall  be  filled  with 
loose  cotton,  and  that  they  shall  be  held  in  place  by  rollers.  It  is 
claimed  for  these  splints  that  they  are  light,  flexible,  permeable  to  air 
and  to  the  perspiration,  and  that  they  permit  the  application  of  cool- 
ing lotions  without  impairing  their  firmness;  the  last  of  which  is  a 
quality  of  questionable  value,  since  lotions  applied  to  permanent 
dressings  of  any  kind  are  only  warm  fomentations,  and  do  not,  there- 
fore, in  this  respect,  serve  the  purpose  for  which  they  were  intended  ; 
besides  that  they  render  the  skin  tender,  and  dispose  it  to  vesicate, 
they  give  rise  to  a  sensation  of  scalding,  which  is  sometimes  almost 
intolerable ;  they  soak  into  the  bed,  and  in  many  other  ways  render 
the  patients  uncomfortable.  Cooling  lotions  are  only  applicable  where 
the  dressings  are  open,  loose,  and  temporary. 

The  same  objections  hold  also  to  this  as  to  all  other  forms  of 
moulded  metallic  or  carved  wooden  splints,  namely,  that  they  seldom 
exactly  fit  the  limb,  even  when  the  supply  of  assorted  sizes  is  com- 
plete, and  that  they  are  not  sufficiently  flexible  to  adapt  themselves 
to  anything  but  the  slightest  irregularity  of  surface.  They  are  not, 
however,  without  merit,  and  they  deserve  at  least  a  qualified  recom- 
mendation in  many  cases.  I  shall  refer  to  them  again  when  speaking 
of  fractures  of  the  thigh  and  leg. 

Horn  and  whalebone  may  be  employed  in  thin  plates,  or  in  the  form 
of  narrow  strips  quilted  into  cloth ;  but  they  are  expensive  and  pos- 
sess no  special  value  except  in  an  emergency.  Reeds,  the  coarse  rank 
grass  which  grows  in  swamps,  flags,  willow  branches,  and  unbroken 
wheat  straw,  may  be  quilted  between  two  thicknesses  of  cloth  in  the 
same  manner,  and  form  very  excellent  temporary  splints.  I  have 
especially  found  it  convenient  to  use  wheat  straw  in  the  form  of  junks. 
Gathering  up  a  bundle  of  unbroken  straws  of  the  size  of  my  arm,  I 
roll  them  snugly  in  a  broad  piece  of  cotton  cloth,  cut  ofi'  the  projecting 
ends  and  then  stitch  up  the  cloth  neatly.  We  have  thus  a  splint  of 
considerable  firmness,  and  one  which  is  cool  and  especially  adapted 
to  the  summer,  allowing  the  perspiration  to  evaporate  freely.  Straw 
splints  were  employed  sometimes  by  Ambrose  Par6,  by  J.  L.  Petit, 
Larrey,  and  I  have  several  times  seen  them  in  the  wards  of  certain 
European  hospitals,  although  I  am  unable  now  to  say  under  whose 

'  Nott  and  Bauer,  Buf.  Med.  Journ.,  vol.  xii.,  April,  1857. 


G-ENERAL    TREATMENT    OF    FRACTURES.  57 

direction.  Mr.  TufFnell,  of  Dublin,  has  especially  recommended  them 
in  the  form  of  junks. 

"Wooden  splints,  made  of  pine,  white  or  linden  wood,  or  of  some 
other  light  and  easily  wrought  timber,  are  probably  of  more  uni- 
versal application,  and  possess  greater  intrinsic  value  than  splints 
constructed  from  any  other  material ;  but  I  wish  at  once,  and  for  all, 
to  disclaim  any  intention  of  giving  even  a  qualified  approval  of  any 
of  those  carved,  polished,  and  generally  patented  wooden  splints,  which 
are  manufactured  and  sold  by  clever  mechanics,  and  which  one  may 
see  suspended  in  almost  every  doctorls  office,  whether  in  the  city  or 
in  the  country.  Constructed  with  grooves  and  ridges,  and  variously 
inclined  planes,  for  the  avowed  purpose  of  meeting  a  multitude  of 
indications,  such  as  to  protect  a  condyle,  to  press  between  parallel 
bones,  to  follow  the  subsidence  of  a  muscular  swelling,  &c.,  they  never 
meet  exactly  a  single  one  of  these  indications,  whilst  they  seldom 
fail  to  defeat  some  other  indication  of  equal  importance.  They  deceive 
especially  the  inexperienced  surgeon  into  the  belief  that  he  has  in  the 
splint  itself  a  provision  for  all  these  wants,  and  consequently  lead  him 
to  neglect  those  useful  precautions  which  he  would  otherwise  have 
adopted. 

If  carved  wooden  splints  are  employed,  they  ought  to  be  made 
especially  for  the  case  under  treatment.  But  this  requires  time  and 
some  more  mechanical  skill  than  can  always  be  commanded  ;  and 
when  accurately  fitted,  it  is  quite  probable  that  the  subsidence  or  in- 
crease of  the  swelling  will,  within  the  next  forty-eight  hours,  render 
some  change  in  the  form  of  the  splint  necessary,  or  compel  the  surgeon 
to  throw  it  aside. 

We  much  prefer  to  use  plain,  straight  strips  of  wood,  of  the  requisite 
width  and  length,  which  may  be  cut  at  any  moment  from  a  shingle  or 
a  thin  piece  of  board. 

In  order  that  these  splints  may  adapt  themselves  to  the  inequalities 
of  the  limb,  and  properly  support  the  fragments,  they  may  be  under- 
laid with  pads  or  junks  of  a  suitable  thickness ;  or,  what  is  still  better, 
they  may  be  covered  with  a  muslin  sack,  open  at  both  ends,  into 
which,  and  on  the  side  of  the  splint  which  is  to  be  placed  against  the 
limb,  bran,  wool,  cotton  batting,  or  curled  hair  may  be  pressed,  until 
it  is  made  to  fit  accurately.  I  generally  prefer  cotton  batting.  Bran 
is  liable  to  get  displaced,  and  curled  hair  does  not  pack  firmly  enough. 
"When  the  sack  is  sufficiently  filled,  the  two  ends  must  be  stitched  up. 
This  mode  of  constructing  the  splint  is  simple  and  easy  of  accomplish- 
ment ;  the  splint  can  be  fitted  very  accurately  ;  the  pad  never  becomes 
displaced ;  and  when  the  bandages  are  applied,  they  may  be  pinned 
or  sewed  to  the  cover  in  such  a  way  that  they  shall  not  slide  or 
loosen. 

If  pads  are  employed  separate  from  the  splint,  and  for  this  purpose, 
also,  I  generally  prefer  the  cotton  batting;  they  ought  to  be  made  and 
fitted  with  the  same  care,  and  neatly  stitched  together  at  their  ends, 
rather  than  pinned.     Cotton  batting  laid  loosely  next  to  the  skin,  or 

'  Tuflfnell,  New  York  Journ.  Med.,  Marcli,  1847,  p.  264. 


58 


GENERAL  TREATMENT  OF  FRACTURES. 


Fig.  9. 


underneath  the  splints  at  any  point,  will  not  keep  its  place  so  well  as 
when  it  is  inclosed  in  covers — it  is  more  liable  to  get  into  knots,  and 
it  has  altogether  a  slovenly  appearance.  The  pads  may  be  stitched  to 
the  roller,  and  in  this  way  secured  efi'ectually  in  place,  but  loose 
cotton  is  subject  to  no  control. 

When  I  speak  of  pads,  it  must  not  be  understood  that  I  intend  to 
recommend  them  for  compresses,  or  for  the  purpose  of  pressing  frag- 
ments into  place.  Nothing  could  be  a  greater  source  of  mischief  in 
the  dressing  of  a  broken  limb.  1  have  only  directed  their  employ- 
ment as  a  means  of  adaptation,  and  to  protect  the  skin  against  the 
direct  pressure  of  the  splint. 

Dr.  Jacob,  of  Dublin,  says  that  he  has  seen  an  excellent  splint  made 
from  the  "fresh  bark  of  a  tree  taken  off  while  the  sap  is  rising."  "It 
fits  admirably,"  says  Dr.  Jacobs,  "just  like  pasteboard  soaked  in  water."^ 
Undressed  sole-leather,  cut  into  shape  and  beaten  with  a  hammer, 
adapts  itself  easily  to  the  limb  and  is  sufficiently  firm.  It  is  especially 
applicable  to  fractures  of  the  larger  limbs. 

A  splint  is  also  occasionally  made  of  thin  calfskin  veneered  with 
some  light  timber,  such  as  linden  or  white-wood,  the  latter  being  sub- 
sequently split  into  strips  of  from  .half  an  inch  to 
one  inch  in  width,  so  as  to  combine  a  certain  degree 
of  flexibility  with  the  requisite  firmness. 

The  Turks  use,  according  to  Sedillot,  in  a  similar 
manner,  the  "  nervures"  of  palm  laid  upon  sheep- 
skin and  fastened  with  wooden  thongs;^  and  Dr. 
Packard  mentions  that  he  has  seen  narrow  slips  of 
some  light  wood  glued  in  the  same  way  upon  soft 
pieces  of  buckskin,  and  then  fastened  together  with 
two  strips  of  buckskin,  which  were  also  glued  to 
the  splints.^ 

Common,  pasteboard,  cardboard,  or  the  stout 
millboard  used  by  bookbinders,  constitute  invaluable  domestic  resorts, 
since  they  can  generally  be  found  in  the  house  of  the  patient ;  and  if 
in  no  other  way,  pasteboard  may  generally  be  had  at  the  expense  of 
some  paper  box  or  of  the  loose  cover  of  some  old  book.  For  small 
bones,  the  thinner  sheets  afford  a  sufficient  support;  but  for  large 
bones  the  thick  binders'  board  is  necessary.  In  preparing  the  latter 
for  use,  it  ought  to  be  moistened  with  water ;  but  if  soaked  too  much 
it  will  separate  and  fall  into  pieces,  or  lose  its  firmness  when  dry,  in 
consequence  of  having  parted  with  some  of  its  paste.  This  splint  may 
be  applied  to  the  limb  without  the  interposition  of  anything  but  a  few 
folds  of  muslin  cloth,  or  a  piece  of  flannel ;  or  we  may  use  instead  a 
single  sheet  of  cotton  wadding.  It  must  be  bound  to  the  limb  by  the 
roller  while  it  is  moist,  and  as  it  dries  speedily  it  forms  a  smooth, 
firm,  and  reliable  splint. 

Felt,  made  of  wool  saturated  with  gum  shellac,  and  pressed  into 

'  Jacobs,  New  York  Journ.  Med.,  March,  1847,  p.  265,  from  Dublin  Med.  Press. 
2  Amer.  Journ.  Med.  Sci.,  vol.  xxiii.,  Feb.  1839,  p.  481. 
^  Packard's  edition  of  Malgaigne,  vol.  i.  p.  173. 


Wood  and  leather  splint. 


GENEEAL  TREATMENT  OF  FRACTURES.  59 

sheets,  makes  an  excellent  moulding  tablet  for  splints.  This  may  be 
obtained  at  any  hat  manufactory.  A  much  cheaper  material,  however, 
and  which  has  nearly  all  of  the  qualities  of  the  real  felt  may  be  made 
from  old  pieces  of  broadcloth,  or  from  any  similar  closely  woven  tex- 
ture, by  saturating  it  thoroughly  with  gum  shellac,  the  gum  being 
dissolved  in  alcohol  in  the  proportions  of  one  pound  of  the  former  to 
two  quarts  of  the  latter.  Thus  prepared,  it  is  to  be  spread  upon  both 
surfaces  of  the  cloth  with  a  common  paint  brush.  When  this  first 
coat  is  well  dried  by  suspending  the  cloth  where  the  air  will  have 
free  access  to  both  surfaces,  a  second  must  be  spread  upon  one  of  the 
surfaces;  and  then  a  third;  the  cloth  being  allowed  to  dry  after  each 
successive  coat.  Finally,  the  sheet  is  to  be  folded  upon  itself,  so  as  to 
bring  the  most  thickly  covered  surfaces  together,  and  pressed  with  a 
hot  flat. 

If  it  is  necessary  to  have  greater  strength,  more  gum  may  be  laid 
upon  the  cloth,  and  it  may  be  again  folded  and  pressed. 

When  used,  it  is  to  be  dipped  into  boiling  water  or  held  near  the 
fire  until  it  becomes  flexible.  It  hardens  very  rapidly  in  cooling,  and 
demands,  therefore,  some  quickness  in  its  application;  but  once  ap- 
plied and  fitted,  it  forms  a  hard  but  smooth  splint  well  adapted  for  all 
the  purposes  for  which  it  is  designed. 

It  is  well  to  mention,  if  one  wishes  to  keep  any  portion  of  the  solu- 
tion which  is  not  used,  that  in  order  to  prevent  evaporation  the  vessel 
in  which  it  is  contained  must  be  closely  covered. 

I  have  used  this  material  for  many  years,  both  in  hospital  and  pri- 
vate practice,  and  I  can  safely  recommend  it  for  all  cases  in  which 
splints  are  required. 

Dr.  Jacob  says  he  has  sometimes  found  an  old  hat  to  furnish  a 
very  efficient  splint  in  the  small  fractures  of  children,  and  I  have  no 
doubt  from  my  experience  with  felt  that  it  might  prove  a  valuable 
resort  in  an  exigency. 

It  has  been  objected  to  this  splint  occasionally,  that  it  is  impervious 
to  air  and  moisture,  and  that  it  confines  the  insensible  perspiration  ; 
an  objection  which  may  be  obviated  in  some  measure  by  rubbing  the 
surface  which  is  to  be  laid  against  the  limb,  with  pumice-stone  until 
it  is  roughened  or  until  a  short  nap  is  raised.  But  as  I  never  use 
splints  of  any  kind  without  underlaying  them  with  compresses  which 
act  sufficiently  as  absorbents,  I  have  never  been  aware  of  any  incon- 
venience from  this  source. 

Within  a  few  years,  sheets  of  gutta  percha  have  been  brought  into 
the  market,  varying  in  thickness  from  the  one-sixteenth  to  one-quarter 
of  an  inch.  For  fractures  of  the  thigh,  and  for  the  large  bones  gene- 
rally, I  prefer  a  thickness  of  about  one-sixth  or  one-fifth  of  an  inch ; 
but  for  the  fingers  or  toes,  it  need  not  be  more  than  one-sixteenth  of 
an  inch  in  thickness.  In  its  natural  state,  and  at  the  ordinary  tempera- 
ture of  the  body,  it  is  nearly  as  hard  and  as  inflexible  as  bone ;  but 
when  immersed  in  boiling  water  it  almost  immediately  softens,  and 
would  melt  completely  unless  soon  removed.  It  can  therefore  be 
adapted  to  any  surface,  however  irregular,  and  its  form  may  be 
changed  as  often  as  may  be  necessary.     It  does  not  harden  quite  as 


60  GENEEAL  TREATMENT  OF  FRACTUEES. 

rapidly  as  felt,  and  it  possesses,  therefore,  in  this  respect  an  advantage, 
since  it  allows  the  surgeon  more  time  for  adjustment;  while,  on  the 
other  hand,  it  hardens  much  more  rapidly  than  either  starch,  paste,  or 
dextrine.  Ten  or  twenty  minutes  is  all  the  time  usually  required  for 
gutta  percha  to  acquire  that  degree  of  firmness  which  will  prevent  it 
from  yielding  under  the  pressure  of  a  bandage. 

To  use  it  skilfully  requires  some  experience,  and  I  have  known 
surgeons  to  reject  it  after  a  single  trial ;  but  by  those  who  have  ac- 
quired the  necessary  skill  it  is  generally  regarded  as  an  invaluable 
resource. 

When  constructing  from  this  material  a  thigh  splint,  we  should 
order  a  very  large  tin  pan,  or  some  open,  flat  tray,  in  which  we  may 
lay  the  splint  at  full  length.  If  the  splint  is  required  to  be  twelve 
inches  long,  and  six  inches  wide,  we  must  cut  it  about  sixteen  inches 
long  by  eight  wide,  so  as  to  allow  for  the  contraction  which  always 
takes  place  more  or  less  when  the  hot  water  is  applied.  It  is  then  to 
be  laid  upon  a  sheet  of  cotton  cloth  of  more  than  twice  the  width  of 
the  splint,  in  order  that  the  cloth  may  envelop  it  completely  when  it  is 
folded  upon  it;  and  the  cloth  should  be  enough  longer  than  the  splint 
to  enable  us  to  handle  and  lift  it  by  the  two  ends  without  immersing 
our  fingers  in  the  hot  water.  Beside,  if  the  gum  is  not  thus  covered 
and  supported  it  will  adhere  to  the  vessel,  to  the  fingers,  to  the  surface 
of  the  limb,  and  indeed  to  whatever  else  it  comes  in  contact  with ;  it 
may  even  fall  to  pieces,  or  become  very  much  stretched  and  distorted 
by  its  own  weight.  The  cloth  cover  will  generally  adhere  to  the 
splint,  and  may  be  permitted  to  remain  iipon  it  permanently. 

Place  the  splint,  thus  covered,  in  the  basin,  and  pour  on  the  water 
at  or  near  the  temperature  of  boiling.  As  soon  as  it  is  sufficiently 
softened,  lift  it  carefully,  and  lay  it  over  the  limb,  and  by  its  own 
weight  it  will  adjust  itself  to  the  surface,  or  it  may  be  moulded  with 
the  hands,  or  by  pressing  it  against  the  limb  with  a  pillow.  If  it  does 
not  harden  rapidly  enough,  this  process  may  be  hastened  by  sponging 
the  outer  surface  with  cold  water;  and  as  soon  as  it  has  acquired 
sufficient  firmness  to  support  itself  it  may  be  removed  and  immersed 
in  a  pail  of  cold  water  or  placed  under  a  hydrant ;  after  this,  it  is  to 
be  neatly  trimmed  and  dried,  when  it  is  ready  for  use. 

The  same  objection  has  been  made  also  to  gutta  percha  which  is 
occasionally  made  to  felt,  namely,  that  it  confines  the  perspiration, 
but  to  this  we  have  already  sufficiently  replied. 

There  is  scarcely  any  fracture  demanding  the  use  of  a  splint  in 
which  I  have  not  demonstrated  its  utility,  but  it  is  especially  valuable, 
as  I  shall  have  occasion  to  mention  again,  as  an  interdental  splint  in 
fractures  of  the  jaw,  and  as  a  moulding  tablet  in  all  fractures  occurring 
in  the  vicinity  of  joints. 

Benjamin  Welch,  of  Lakeville,  Conn.,  has  contrived  a  very  inge- 
nious application  of  gutta  percha  to  the  purposes  of  a  splint,  by 
veneering  a  thin  plate  of  the  gum  with  equally  thin  plates  of  elastic 
wood.  The  veneering  is  laid  upon  both  sides,  and  then  it  is  pressed 
into  form  in  moulds.     The  elasticity  of  the  wood,  together  with  the 


GENEEAL  TREATMENT  OF  FRACTURES. 


61 


plasticity  of  the  gum,  enables  the  surgeon  to  change  its  form  some\Yhat 
at  pleasure,  by  dipping  it  into  hot  water. 


Fisr.  10. 


Fig.  11. 


"Welcli's  veneered  gutta-perclia,  dorsal  and  palmar  splints  for  forearm. 

Its  form  cannot,  however,  be  changed  to  any  great  extent,  and  by 
frequent  immersion  in  hot  water  the  veneering  is  apt  to  loosen  from 
the  gutta  percha.  Nevertheless  it  is  a  most  excellent  splint,  and  in 
very  many  respects  it  is  superior  to  any  of  the  carved  wooden  splints 
which  we  have  ever  seen. 

The  moulding  tablet  of  Alfred  Smee, 
composed  of  gum  Arabic  and  whiting, 
spread  upon  cloth,*  has  nothing  spe- 
cial to  recommend  it,  any  more  than 
the  cloth  splints,  hardened  with  the 
whites  of  eggs  and  flour,  used  by  Larrey  .^ 
Starch  and  alum,  glue,  pitch,  and  vari- 
ous other  materials  of  a  similar  character 
deserve  only  to  be  mentioned  as  having 
been  occasionally  employed,  but  which 
have  never  succeeded  in  securing  for 
themselves  the  confidence  of  surgeons. 

In  1834,  Suetin,  of  Brussels,  intro- 
duced the  use  of  starch  as  a  means  of 
hardening  the  bandages  ;  his  method  of 
using  which  is  essentially  as  follows.  A 
dry  roller  is  first  applied  to  the  skin, 
and  then  smeared  with  starch ;  all  of 
the  bony  prominences  and  irregularities 
of  the  limb  are  filled  up  or  covered  with 
cotton  batting,  charpie,  down,  etc.;  strips 
of  pasteboard,  or  of  binders'  board, 
moistened  and  covered  also  with  starch, 
are  now  laid  alongside  the  limb,  over 
which  again  are  turned  in  succession 
one,  two,  or  three  layers  of  the  starched 
roller ;  the  number  of  rollers  and  the  thickness  of  the  pasteboard  being 
proportioned  to  the  size  of  the  limb,  or  to  the  required  strength  of  the 

'  Amer.  Joum.  Med.  Sci.,  vol.  xxvi.  p.  220,  May,  1840  ;  from  London  Lancet,  Jan. 
25,  1840. 

^  Amer.  Journ.  Med.  Sci.,  vol.  ii.  p.  216,  May,  1828  ;  from  Journal  des  Progres,  voL  iv. 


Starch  bandage,  applied  for  a  broken 
thiffli. 


62  GENERAL  TREATMENT  OF  FRACTURES. 

splint.  The  wliole  is  completed  by  starching  the  outside  of  the  last 
bandage. 

This  dressing  will  generally  become  dry  within  from  thirty  to  forty 
hours ;  which  process  may  be  expedited  by  exposing  its  sides  as  much 
as  possible  to  the  air,  or  by  the  application  of  artificial  heat  with  bags 
of  dry  sand,  or  with  hot  bricks.  As  a  temporary  support  until  the 
drying  is  completed,  some  surgeons  lay  upon  each  side  of  the  limb 
additional  splints,  securing  them  in  place  with  tapes. 

As  soon  as  the  bandages  are  dry  they  are  to  be  cut  along  the  front 
to  a  sufficient  extent  to  permit  of  an  examination  of  the  limb,  and  then 
closed  with  an  additional  roller.  For  the  purpose  of  opening  the 
bandages  both  at  this  period  and  subsequently,  Suetin  uses  a  pair  of 
strong  scissors  or  pliers,  such  as  are  represented  in  Fig.  1^. 

Fig.  13. 


Suetin's  pliers. 

On  the  third  or  fourth  day,  or  as  soon  as  the  subsidence  of  the  swell- 
ing may  render  it  necessary,  the  bandages  should  be  cut  open  through 
their  whole  extent,  the  edges  pared  ofl'  and  brought  together  again 
snugly  with  an  additional  roller. 

Erichseu,  who  uses  the  starch  bandage  in  all  fractures  and  from  the 
first  day,  advises  that  the  limb  shall  be  completely  enveloped  with 
cotton  wadding  before  the  first  roller  is  applied  ;  in  consequence  of 
which  he  does  not  think  it  necessary  to  apply  the  first  roller  dry. 

Yelpeau  prefers  dextrine  ("British  gum")  a  kind  of  glue  or  jelly 
obtained  by  the  continued  action  of  diluted  sulphuric  acid  upon  starch 
at  the  boiling  point.  It  is  prepared  for  use  by  dissolving  it  in  alcohol 
or  tincture  of  camphor,  or  camphorated  brandy,  until  it  has  acquired 
about  the  consistence  of  honey ;  at  this  point  hot  water  should  be 
added,  reducing  its  consistence  to  that  of  thin  treacle,  when,  after  one 
or  two  minutes'  shaking,  it  is  ready  for  application.  According  to  F. 
D'Arcet,  the  proportions  most  favorable  to  the  drying  and  solidifying 
of  the  apparatus  are,  one  hundred  parts  of  dextrine,  sixty  of  cam- 
phorated brandy,  and  fifty  of  water.  Malgaigne,  to  whom  I  am  in- 
debted for  this  observation  of  D'Arcet,  says,  also,  in  a  note,  "as  regards 
dextrine,  an  important  point  was  recently  brought  practically  under 
my  notice,  viz.,  that  as  sold  in  the  shops,  it  is  often  unfit  for  making 
an  agglutinative  mixture ;  it  forms  lumps  with  alcohol,  as  starch  does 
with  cold  water,  without  cohering;  and  twice  in  succession  I  have 
been  obliged  to  change  the  supply  at  the  Hopital  Saint  Antoine.  The 
dextrine  thus  deteriorated  is  whiter  and  less  saccharine ;  it  crepitates 
more  in  the  fingers;  and  on  pouring  a  few  drops  of  tincture  of  iodine 
into  the  solution,  there  is  produced  a  violet  tint,  indicating  the  pre- 


GENERAL  TREATMEXT  OF  FRACTURES.  63 

sence  of  fecula;  while  true  dextrine,  treated  with,  iodine,  gives  a  yinous 
red,  or  the  color  of  onion  peel." 

Telpeau  soaks  his  bandages  with  the  dextrine  before  applying  them, 
but  like  Suetin,  he  applies  his  first  roller  dry.  He  uses  but  one  band- 
age, which  he  carries  first  from  below  upwards  and  then  from  above 
downwards;  and  he  rarely  thinks  it  necessary  to  employ  the  paste- 
board as  a  collateral  support. 

For  myself  I  am  quite  as  much  in  the  habit  of  using  wheat  flour 
paste  as  either  starch  or  dextrine,  and  if  properly  made  it  dries  about 
as  quickly  as  the  starch,  and  is  equally  firm. 

Whatever  material  is  used  in  the  construction  of  what  is  now  usually 
termed  the  "  immovable  apparatus,"  or  as  Suetin  has  more  lately  called 
it,  the  "  m.ovable  immovable  apparatus,"  ("  movo-amobile")  in  reference 
to  his  practice  of  opening  it  at  an  early  period,  it  is  still  the  same 
apparatus  in  effect,  and  is  liable  to  the  same  judgment — a  judgment 
which  we  shall  find  it  very  difficult  to  declare,  since,  from  the  day  in 
which  this  practice  was  first  recommended  by  Suetin,  to  the  present 
moment,  it  has  been  constantly  experiencing  the  most  extraordinary 
vicissitudes  in  the  public  favor.  At  one  time,  and  by  the  most  ex- 
perienced surgeons,  extolled  as  a  method  unequalled  in  its  simplicity, 
efficiency,  and  safety,  and  at  another,  and  by  surgeons  of  equal  experi- 
ence, denounced  as  eminently  lacking  in  all  of  the  true  essentials  of 
an  apparatus  for  broken  limbs.  These  conflicting  opinions,  which  it  is 
impossible  to  reconcile,  have  nevertheless  some  foundation  in  truth. 
The  immovable  apparatus,  of  whatever  materials  constructed,  is  under 
some  circumstances  a  very  simple,  safe,  and  efficient  dressing,  while 
under  other  circumstances  it  is,  as  we  think,  eminently  unsafe  and  ineffi- 
cient. Thus,  in  all  of  those  fractures  which  are  accompanied  with  such 
injury  to  the  soft  parts  as  to  render  subsequent  inflammation  inevitable 
or  probable,  this  form  of  dressing  exposes  to  congestions,  strangula- 
tions, and  gangrene.  Whatever  its  advocates  may  say  to  the  contrary, 
the  simple  fact  is  before  us,  that  the  number  of  accidents  resulting  from 
this  practice  is  out  of  all  proportion  with  any  other  yet  introduced.  I 
have  met  with  them  myself  in  all  parts  of  my  own  country,  and  the 
journals  abound  with  records  of  disasters  from  this  source.'  Nor  is  it 
a  sufficient  reply  to  this  statement,  that,  with  proper  care  and  prudence, 
such  accidents  may  be  avoided.  We  think  they  could  not  always  be 
avoided.  But  admitting  that  they  could,  it  is  still  undeniable  that  in 
certain  cases  the  immovable  apparatus  demands  extraordinary  atten- 
tion; and  what  is  the  need  of  multiplying  our  cares  when  already  they 
are  more  than  sufficient  ?  Many  circumstances,  over  which  he  has  no 
control,  may  prevent  the  surgeon  from  giving  to  the  limb  the  full 
amount  of  attention  which  is  required ;  and  for  this  reason  that  appa- 
ratus is  the  best  which,  whilst  it  answers  the  indications  equally  well, 
exacts  the  least  amount  of  skill  and  attention  on  the  part  of  the  surgeon. 

Immovable  dressings  are  not  only  liable  to  become  too  tight  as  the 
swelling  augments,  but,  on  the  other  hand,  the  surgeon  may  omit  to 
notice  that  as  the  swelling  has  subsided  it  has  become  loose.     Portions 

'  See  Amer.  Journ.  Med.  Sci.,  vol.  xxv.  p.  450,  Feb.  1S40  ;  also  vol.  sxxi.  p.  212. 


64 


GENERAL  TREATMENT  OF  FRACTURES. 


of  the  limb  may  vesicate,  ulcerate,  or  even  slough,  without  the  know- 
ledge of  the  surgeon.  If,  however,  the  bandages  are  frequently  opened 
and  all  the  proper  precautions  are  taken,  it  is  possible  that  these  acci- 
dents may  also  be  avoided ;  but  unfortunately  experience  has  shown 
that  they  have  not  been  avoided  in  too  many  instances. 

The  cases,  then,  to  which  this  apparatus  seems  to  be  adapted,  are  a 
few  examples  of  transverse  or  serrated  fractures  in  which  the  bones 
have  not  become  displaced,  and  in  which  little  or  no  swelling  is  anti- 
Fig.  14. 


Fig.  15. 


Opening  tlie  apparatus  with  Suetin's  pliers. 

cipated  ;  and  in  certain  fractures  which  were  originally  more  compli- 
cated, but  in  which  a  partial  union,  and  the  subsidence  of  the  inflam- 
mation, have  reduced  them  to  a  more  simple  condition ;  and  especially 
in  cases  of  delayed  union.  If  now  the  dressings 
are  applied  carefully,  the  bandage  being  only 
moderately  tight,  and  a  portion  of  the  extremity 
of  the  limb  is  left  uncovered  so  that  we  may 
observe  constantly  its  condition,  and  at  proper 
intervals  the  apparatus  is  opened  completely  in 
order  that  we  may  subject  the  whole  limb  to  a 
thorough  examination ;  in  such  cases  as  we 
have  now  indicated  and  with  such  precautions, 
we  admit  that  the  "apparatus  immobile"  con- 
stitutes an  invaluable  surgical  appliance,  and 
one  of  which  no  surgeon  can  well  afford  to  be 
deprived. 

I  have  even  met  with  examples  of  compound 
fractures  in  which  it  has  seemed  proper  to  ap- 
ply this  dressing;  but  only  when  a  sufficient 
time  had  elapsed  to  render  it  probable  that 
there  would  be  no  sudden  accession  of  swelling 
in  the  limb.  In  such  cases  I  have  preferred 
generally  to  lay  the  several  turns  of  the  roller 
directly  over  the  suppurating  wound  in  the 
same  manner  as  if  no  wound  existed,  and  to 
"Apparatus  in^moMie"  ap-     ^^^^  ^  valvukr  Opening,  or  window,  with  the 

plied   over  a  compound  frac-  .  inn-  i  •  i  n 

ture.  scissors  on  the  lollowing  day  in  order  to  allow 


GEXEEAL  TREATMENT  OF  FRACTURES.  ()5 

the  matter  to  escape,  after  which  the  valve  may  be  laid  down  and 
stitched,  or  the  piece  may  be  removed  entirely,  and  a  new  piece  of 
bandage  drawn  closely  around  the  limb  at  this  point.  This  may  be 
repeated  once  or  twice  daily.  If  an  opening  is  left  by  the  roller,  and 
no  additional  bandage  is  laid  over  it,  the  margins  of  the  wound  soon 
become  cedematous  and  protrude,  making  an  ugly-looking  and  ill- 
conditioned  sore. 

Plaster  of  Paris  moulds,  employed  occasionally  from  a  very  early 
period,  and  more  lately  recommended  by  Hendriksz,  Hubenthal,  Keyl, 
and  Dieffenbach,  are  not  entitled  to  serious  consideration.  Heavy 
stone  coffins,  they  might  serve  well  enough  the  purposes  of  interment, 
but  they  are  wholly  unsuited  to  the  purposes  of  a  splint. 

Plaster  of  Paris  has,  however,  been  of  late  employed  in  another 
form,  and  in  relation  to  which  our  judgment  must  be  much  more 
favorable.  I  allude  to  the  so-called  "  plaster  of  Paris  bandages,"  which  . 
were  first  introduced  to  notice  by  Mathiesen  and  Van  der  Loo,  of 
Holland,  but  the  value  of  which  has  been  more  especially  brought  to 
notice  by  Prof.  Nicholas  Pirogoff,  of  St.  Petersburg,  the  late  Surgeon- 
in-chief  at  Sebastopol. 

The  manner  of  using  the  gypsum  bandages  is  as  follows:  A  dry 
roller  is  first  applied  to  the  limb,  or  it  may  be  covered  with  a  single 
piece  of  cloth  of  any  kind,  and  the  irregularities  are  filled  up  and 
protected  with  cotton  wool,  the  same  as  we  have  directed  when  about 
to  apply  the  starch  bandage.  The  remaining  dressings  being  now  at 
hand  and  ready  for  use,  we  proceed  to  mix  the  plaster.  For  this  pur- 
pose we  must  select  the  fine,  fresh,  well-dried,  white  powder.  The 
gray  does  not  solidify  well,  nor  that  which  has  been  a  long  time 
ground,  or  is  moist.  The  proportions  of  water  and  plaster  usually 
required  are  about  equal  parts  by  weight.  For  the  thigh  it  may  re- 
quire, perhaps,  seven  or  eight  pounds  of  plaster,  and  for  the  leg  or 
arm  much  less.  It  is  probably  a  better  rule  to  direct  the  gypsum  to 
be  added  to  the  water  until  it  is  of  about  the  consistence  of  cream. 
The  water  should  be  cold  and  the  gypsum  thrown  in  not  too  rapidly, 
at  least  not  more  rapidly  than  it  can  be  thoroughly  mixed,  otherwise 
we  shall  not  be  able  to  determine  precisely  its  consistence.  If,  while 
applying  the  paste,  it  begins  to  harden  in  the  bowl,  we  must  not  add 
more  water,  as  this  will  again  interfere  with  its  final  solidification  upon 
the  limb.  It  must  be  thrown  away  and  some  fresh  immediately  pre- 
pared; or  the  crystallization  may  be  retarded  by  throwing  in  a  few 
drops  of  carpenters'  glue.  When  the  plaster  is  good,  and  it  is  pro- 
perly mixed,  we  may  allow  ourselves  from  five  to  eight  minutes  iu 
the  application.  A  large  paint  brush  is  the  most  convenient  thing  for 
spreading  it,  but  the  hands  will  do  very  well  in  an  emergency. 

Everything  being  ready,  the  limb  is  to  be  seized  by  assistants  at 
both  of  its  extremities  and  held  in  a  position  of  steady  extension  until 
the  dressing  is  completed,  and  for  one  or  two  minutes  longer,  or  until 
the  plaster  is  hard.  It  will  be  sufficiently  hard  to  support  itself  even 
when  the  dressings  are  quite  moist.  The  surgeon  then  proceeds  to 
lay  a  long  piece  of  linen — old  sack  will  answer  as  well  as  any — folded 
three  or  four  times,  and  saturated  with  the  paste,  parallel  to  the  two 
5 


66  GENERAL  TREATMENT  OF  FRACTURES. 

sides  of  tlie  limb,  around  which  are  to  be  immediately  placed  horizon- 
tally, and  at  several  points,  short  and  wide  strips  of  the  same  material. 
These  latter  are  intended,  to  increase  the  strength  of  the  apparatus,  and 
to  bind  on  the  side  strips.  Finally,  the  whole  may  be  painted  with 
the  solution.  It  is  very  well,  however,  not  to  cover  the  front  of  the 
limb,  or  a  narrow  strip  somewhere  in  the  line  of  the  axis  of  the  limb, 
with  the  plaster,  as  this  will  not  diminish  materially  its  strength,  and 
it  will  enable  the  surgeon  to  open  it  more  easily  with  the  scissors. 
Pirogoff  accomplishes  the  same  purpose  by  laying  a  piece  of  narrow 
tape,  soaked  in  oil,  along  the  line  through  which  he  wishes  to  make 
the  section  of  the  splint.^ 

Another  mode  of  applying  the  gypsum  is  to  employ  common  rollers, 
made  of  unglazed,  open  calico.  The  cloth,  being  torn  into  strips  of  a 
suitable  width  and  length,  is  laid  upon  a  table,  and  the  dry  plaster 
rubbed,  into  it  for  several  minutes,  until  its  meshes  are  well  and  evenly 
filled.  Each  bandage  is  then  rolled  up  closely,  and  immediately  before 
being  applied  a  little  water  must  be  dropped  into  the  extremities  of 
the  roll  to  moisten  the  plaster,  but  not  enough  to  soak  through  the 
plaster  and  thereby  wash  it  out.  Thus  prepared,  the  gypsum  roller 
is  applied  to  the  limb  in  circular  turns,  until  the  whole  is  completely 
encased  with  one  or  two  layers,  Eeversed  turns  must  be  avoided  as 
far  as  possible,  and  when  they  become  necessary,  the  fold  should  not 
be  made  over  a  projecting  ridge  of  bone,^ 

I  have  omitted  to  mention  that  the  limb  must  be  completely  covered 
and  protected  with  a  dry  roller  and  with  cotton  pads  or  compresses, 
before'  the  gypsum  roller  is  applied. 

All  that  we  have  before  said  of  the  advantages  and  hazards  of  the 
"apparatus  immobile,"  are  equally  applicable  to  this  form  of  the 
apparatus,  or  at  least  with  only  slight  modifications.  It  dries  much 
more  rapidly ;  but  this  apparent  advantage  is  sometimes  more  than 
counterbalanced  by  the  necessity  of  haste  in  its  application,  and  the 
consequent  danger  of  having  done  our  work  in  a  slovenly  manner. 
No  doubt,  on  the  field  of  battle,  and  in  army  surgery  generally,  the 
speed  with  which  it  becomes  hard  and  firm,  would  secure  for  it  a  pre- 
ference over  almost  any  other  form  of  dressing,^ 

Professor  B,  W.  Dudley,  of  Lexington,  Ky.,  one  of  themost  successful 
surgeons  in  this  country,  but  especially  distinguished  as  a  lithotomist, 
has  for  many  years  employed  m  the  treatment  of  fractures  nothing 
but  a  roller,  regarding  both  side  splints  and  extending  apparatus  as 
not  only  useless  but  absolutely  pernicious.'*  This  practice,  which 
seems  to  have  originated  with  Eadley,  of  England,  has  not  found, 
hitherto,  in  this  country  or  elsewhere,  many  imitators ;  and  although 
one  ought  in  general  to  speak  very  cautiously  of  a  practice  which  he 
has  never  seen  tried,  and  especially  when  it  brings  with  it  the  au- 

'  Weber  on  Plaster  of  Paris  Bandage,  New  York  Journ.  Med,,  May,  1856,  p,  341, 

2  Gamgee's  Researches,  London,  1856,  p,  154, 

'  Practical  Lectures  on  Military  Surgery,  by  Isidor  Gliick,  of  New  York,  chief  sur- 
geon to  the  Hungarian  (Vilmos)  Hussars,  &c.  &c.,  during  the  late  war  in  Hungary, 
Amer.  Med.  Monthly,  Dec.  1855,  p.  449,  &c.,  vol.  iv. 

*  Dudley,  Trans,  Amer,  Med,  Assoc,  vol,  iii.,  1850,  p.  349. 


GENEEAL    TEEATilEXT    OF    FEACTUEES.  67 

thority  of  so  distinguished  a  surgeon  as  Dr.  Dudley,  I  do  not  hesitate 
to  pronounce  it  irrational,  and  to  declare  my  belief  that  it  is  in  no  way 
entitled  to  the  confidence  of  the  profession. 

Still  more  unscientific,  and  absurd  even,  is  the  practice  of  Jobert, 
of  Paris,  who  employs  neither  side  splints  nor  bandages,  but  only 
extension,  in  the  treatment  of  all,  or  of  nearly  all  fractures  of  the  long 
bones. 

As  to  the  question  of  permanent  extension  in  fractures,  and  the 
means  by  which  it  may  be  most  eflectually  accomplished,  nothing 
need  be  said  at  this  time,  inasmuch  as  it  relates  only  to  the  fractures 
of  certain  bones,  and  to  certain  forms  of  fractures ;  we  must  therefore 
refer  its  consideration  to  those  chapters  which  treat  of  individual 
bones. 

In  the  treatment  of  comminuted  fractures,  no  pains  ought  to  be 
spared  to  bring  the  fragments  as  nearly  as  possible  into  apposition ; 
and  if  there  exists  at  the  same  time  an  external  wound,  and  the  frag- 
ments are  small  and  loose,  they  ought  to  be  removed  carefully.  ISTor, 
indeed,  should  we  be  deterred  from  the  attempt  to  remove  them  by 
finding  that  they  are  adherent,  if  still  they  are  easily  moved  about 
with  the  finger. 

In  compound,  fractures,  not  unfrequently  the  end  of  one  of  the  frag- 
ments protrudes  from  the  wound,  and  its  reduction  may  be  attended 
with  considerable  difficulty.  My  practice  is  usually  in  such  cases  to 
attempt  the  reduction  first,  by  simple  extension  and  counter-exten- 
sion; but  if  this  fails,  I  introduce  my  finger  into  the  wound,  and 
endeavor  to  stretch  the  skin  over  the  sharp  point  of  bone;  or  I  make 
use  of  a  spatula  formed  from  a  piece  of  shingle,  or  of  any  suitable 
piece  of  metal  which  may  be  at  hand ;  finally,  but  not  until  all  other 
expedients  have  failed,  I  enlarge  the  wound  sufficiently  to  insure  its 
return. 

There  are  some  cases,  however,  in  which  the  surgeon  may  feel 
justified  in  sawing  off  the  projecting  end  ;  as  when  the  periosteum  is 
completely  torn  from  it  by  its  having  penetrated  a  boot,  or  even  some- 
times when  its  extremity  is  very  sharp,  and  there  is  reason  to  suppose 
that  it  would  prick  and  irritate  the  tissues. 

If  arteries  bleed  freely  and  for  a  long  time,  we  may  make  some 
effort  to  find  the  open  mouths  in  the  wound,  but  in  this  we  rarely 
succeed,  nor  is  it  prudent  always  to  tie  the  main  branch  which  supplies 
the  limb.  Fortunately  this  bleeding,  although  at  first  profuse,  gene- 
rally ceases  in  a  few  hours  under  the  steady  employment  of  cold  lotions, 
moderate  compression,  and  rest.  If  it  does  not,  the  chances  are  that 
the  case  will  call  for  amputation. 

The  rule  generally  laid  down  by  surgeons  that  we  should  at  once 
close  the  wound  in  compound  fractures,  with  sutures  and  adhesive 
straps  if  necessary,  or  with  bandages,  is  far  too  absolute.  This  prac- 
tice will  do  when  there  is  no  great  contusion  or  extravasation  of  blood, 
but  if  blood  is  flowing  it  is  much  better  to  leave  the  wound  open  so 
as  to  permit  it  to  escape  freely ;  and  if  the  severity  of  the  injury  war- 
rants the  supposition  that  much  inflammation  is  to  ensue,  the  danger 


68  DELAYED    AND    NON-UNION    OF    BROKEN    BONES. 

of  gangrene  is  greatly  lessened  by  thus  allowing  the  opening  to  remain 
as  a  channel  of  exit  for  the  inflammatory  effusions. 

Many  years  since  Dr.  J.  Rhea  Barton  introduced  into  the  Pennsyl- 
vania Hospital  what  has  since  been  called  the  "  bran  dressing"  for  the 
treatment  of  compound  fractures  of  the  leg  ;  the  limb  being  made  to 
repose  in  a  box  filled  with  this  material.'  I  have  used  it  very  fre- 
quently, and  can  speak  of  it  as  possessing  many  qualities  of  excellence, 
especially  as  a  summer  dressing.  The  particular  mode  of  using  this 
apparatus  I  shall  describe  more  minutely  when  treating  of  fractures  of 
the  leg. 

The  treatment  of  inflammatory  symptoms,  and  of  the  later  accidents, 
such  as  suppuration,  oedema,  gangrene,  &c.,  must  be  left  mainly  to  the 
good  judgment  of  the  surgeon.  Gentle  manipulation,  uniform  sup- 
port, rest  and  sometimes  cooling  lotions  constitute  the  most  important 
means  by  which  inflammation  is  to  be  controlled.  Bleeding  is  rarely 
necessary,  and  in  a  large  majorit}'-  of  cases  it  might  prove  injurious  by 
lowering  too  much  the  vital  forces,  which  need  to  be  husbanded  in 
view  of  the  requirements  of  the  process  of  repair  and  of  the  long  and 
exhausting  confinement.  Cathartics  should  also  be  administered  cau- 
tiously for  the  same  reason,  and  because  they  are  liable,  especially  in 
fractures  of  the  lower  extremities,  to  occasion  a  serious  disturbance  of 
the  limb. 


CHAPTER    VI. 

DELAYED  UNION  AND  NON-UNION  OF  BROKEN 

B0NES.2 

Most  surgical  writers  concur  in  the  statement  that  non-union  of 
broken  bones  is  an  uncommon  event.  Walker,  of  Oxford,  affirms 
that  of  not  less  than  one  thousand  fractures  which  have  come  under 
his  treatment  at  some  period  of  the  repair,  he  does  not  recollect  more 
than  six  or  eight  instances.  According  to  Lonsdale,  not  more  than 
five  or  six  cases  of  false  joint,  excepting  those  within  a  capsule,  have 
occurred  out  of  nearly  four  thousand  fractures  treated  at  the  Middle- 
sex Hospital.  In  a  table  of  367  cases,  collected  and  arranged  by  W. 
W.  Morland,  from  the  books  of  the  Massachusetts  General  Hospital, 
extending  through  a  period  of  nineteen  years,  only  one  example  of 

'  Paper  on  Bran  Dressings,  by  Reynell  Coates,  of  Pliiladelpliia.  Amer.  Journ.  Med. 
Sci.,  April,  1842,  p.  515  ;  from  the  Med.  Examiner,  Nos.  9  and  11,  vol.  i.,  New  Series. 

2  I  shall,  in  this  chapter,  avail  myself  freely  of  the  labors  of  George  W.  Norris,  of 
Philadelphia,  whose  paper,  entitled  "  On  the  Occun-ence  of  Non-union  after  Fractures, 
its  Causes  and  Treatment,"  published  in  the  American  Journal  of  Medical  Sciences  for 
Jan.,  1842,  constitutes  the  most  complete  and  reliable  monograph  upon  this  subject 
contained  in  any  language. 


DELAYED    AND    NONUNION    OP    BROKEN    BONES.  69 

false  joint  is  recorded;  but  as  only  seventy-four  days  had  elapsed 
when  this  patient  was  discharged,  it  is  doubtful  whether  this  might 
not  have  proved  to  be  a  case  of  delayed  union  simply.^  Of  9-i6  cases 
of  recent  fracture  treated  in  the  Pennsylvania  Hospital  between  the 
years  1830  and  1840,  no  instance  of  false  union  followed  the  treatment 
pursued.^  Sir  Stephen  Hammick,  Mr.  Liston,  and  Malgaigne  affirm 
also  the  infrequency  of  these  accidents  in  the  cases  which  have  come 
under  their  personal  treatment.  I  have  myself  seen  a  considerable 
number  of  examples  of  non-union,  but  in  not  one  of  my  own  cases, 
whether  in  hospital  or  private  practice,  has  the  bone  refused  finally  to 
unite ;  and  my  opinion  is,  that  in  proportion  to  the  number  of  fractures 
everywhere,  these  cases  are  very  rare,  perhaps  not  in  a  larger  propor- 
tion than  one  in  five  hundred. 

Amesbury  alone  seems  to  have  entertained  a  contrary  opinion. 
His  own  experience  having  supplied  fifty-six  examples  of  what  he  has 
called  "  fractures  of  long  standing."  Norris  remarks  that  he  is  "  at  a 
loss  to  account  for  its  frequency  in  his  practice,  but  a  reviewer  of  his 
own  nation  observes  of  his  statement  that  the  surgery  of  fractures 
must  be  singularly  bad,  where  one  individual  has  had  occasion  to 
number  fifty-six  examples  of  non-union,  even  making  allowance  for 
the  fact,  that  all  the  bad  cases  came  to  Mr.  Amesbury."  I  notice,  also, 
that  at  a  later  period  Mr.  Amesbury's  experience  in  false  joint  extended 
to  ninety  cases. 

The  humerus  and  femur  would  appear  to  be  the  bones  most  liable 
to  non-union,  as  shown  by  Norris's  statistics ;  in  which  forty-eight  be- 
longed to  the  humerus,  forty-eight  to  the  femur,  thirty -three  to  the  leg, 
nineteen  to  the  forearm,  and  two  to  the  jaw.  In  my  own  experience, 
I  have  found  the  humerus  ununited  much  more  often  than  the  femur. 

B^rard  has  shown  that  in  the  growth  of  the  long  bones  the  period 
at  which  the  epiphyses  are  united  to  the  diaphyses  depends  upon  the 
direction  of  the  nutritive  artery ;  for  example,  "  it  is  found  that  in  the 
humerus,  where  the  direction  of  this  vessel  is  from  above  downwards, 
consolidation  takes  place  soonest  at  its  inferior  extremity.  In  the  fore- 
arm, the  course  of  the  nutrient  vessels  is  from  below  upwards,  and 
here  consolidation  of  the  epiphyses  is  found  to  occur  at  the  elbow 
sooner  than  at  the  wrist.  In  the  inferior  members,  on  the  contrary, 
the  epiphyses  composing  the  knee  are  the  last  which  become  firm, 
because  in  the  femur  the  nutritious  artery  runs  upwards,  and  in  the 
bones  of  the  leg  it  courses  from  above  downwards."  A  knowledge  of 
these  facts  led  Gueretin  to  inquire  into  the  influence  of  these  art^ies 
upon  the  consolidation  of  fractures ;  and  the  cases  collected  by  him 
did  indeed  seem  to  show  a  positive  relation  between  the  direction  of 
the  artery  and  the  union  of  the  bone ;  that  is  to  say,  the  examples  of 
non-union  were  chiefly  found  where  the  fracture  had  taken  place  on 
that  side  of  the  nutritious  foramen,  from  which  the  artery  entered,  as 
if  to  imply  that  the  non-union  was  in  some  measure  due  to  the  imper- 
fect nutrition  of  this  extremity  of  the  bone.     In  thirty-five  cases  of 

'  Address  on  Fractures,  by  A.  L.  Peirson,  read  before  the  Massachusetts  Med.  Soc. 
May  27,  1840. 
2  Norris,  loc.  cit. 


70  DELAYED    AND    NON-UNION    OF    BROKEN    BONES. 

non-union  analyzed  by  Gu^retin,  ten  belonged  to  that  portion  of  the 
bone  which  was  traversed  by  the  artery,  and  twenty-five  to  the  other 
portion.  But  an  analysis  of  forty-one  cases,  made  by  Norris,  does  not 
seem  to  confirm  this  observation  of  Gueretin,  since  twenty-seven  were 
in  the  direction  of  the  nutritious  arteries,  and  only  fourteen  in  the 
opposite  portion,  or  in  that  which  is  supposed  to  be  less  nourished. 

Another  observation  made  by  Curling,  that  in  fractures  of  the  long 
bones  the  portion  below  the  entrance  of  the  nutrient  artery,  or  on  that 
side  of  the  nutritious  foramen  towards  whicih  the  blood  flows,  being 
defrauded  of  its  proper  supply,  is  subjected  to  a  species  of  atrophy, 
presenting  a  larger  medullary  canal,  with  thinner  walls,  and  a  spongy 
tissue  less  dense,  also  needs  confirmation.  Malgaigne  has  not  noticed 
this  fact  in  any  of  the  specimens  contained  in  the  public  museums  of 
Paris ;  and  we  do  not  know  that  any  other  writer  has  made  the  ques- 
tion a  subject  of  especial  inquiry. 

According  to  Norris,  there  are  four  principal  kinds  of  false  joint: — 
In  the  first,  the  bones  are  united  and  completely  enveloped  in  a  car- 
tilaginous mass  or  callous  tumor,  but  in  consequence  of  some  retarda- 
tion in  the  process  bony  matter  is  not  deposited,  and,  as  a  consequence, 
it  wants  solidity,  the  part  continuing  easily  movable.  This  may  be 
regarded  as  a  proper  example  of  delayed  union,  as  distinguished  from 
complete  non-union,  or  false  joint. 

In  the  second,  there  is  entire  want  of  union  of  any  sort  between 
the  fragments,  the  ends  of  which  seem  to  be  diminished  in  size  and 
extremely  movable  beneath  the  integuments.  The  limb  in  these  cases 
is  found  wasted  and  powerless. 

In  the  third  and  most  common  class,  the  medullary  canal  is  oblite- 
rated in  both  fragments,  and  the  ends 
^^S-  IS.  are  more  or  less  absorbed,  rounded, 

and  covered,  in  part  or  in  whole, 
with  a  dense  tissue  resembling  the 
periosteum.  A  connection  also  exists 
between  the  opposing  fragments  in 
the  form  of  strong  ligamentous  or  fibro-ligamentous  bands,  which,  if 
of  any  length,  are  quite  flexible,  and  allow  of  considerable  motion  at 
the  seat  of  fracture. 

In  the  fourth,  "  a  dense  capsule  without  opening  of  any  kind  con- 
taining a  fluid  similar  to  synovia,  and  resembling  closely  the  complete 
ligaments,  is  found.''  In  these  cases  the  points  of  the  bony  fragments 
corresponding  to  each  other,  are  rounded,  smooth  and  polished,  in 
some  instances  eburnated,  and  in  others  covered  with  points  or  even 
thin  plates  of  cartilage,  and  a  membrane  closely  resembling  the  syno- 
vial of  the  natural  articulation."  It  is  in  this  kind  of  cases,  Norris 
remarks,  that  the  member  affected  may  still  be  of  use  to  the  patient, 
the  fragments  being  so  firmly  held  together  as  to  be  displaced  only 
upon  the  application  of  considerable  force. 

The  existence  of  these  newly  formed  joints,  or  true  diarthroses, 
has  been  called  in  question  by  Boyer,  Hewson,  Chelius^  and  others ; 

'  Malad.  Chirurg.,  t.  iii.  p.  103,  Paris,  1831 ;  North  Amer.  Med.  and  Surg.  Journ.,  No. 
ix.  p.  7,  1828 ;  Trait,  de  Chir.,  trad,  par  Pigne,  p.  150,  1836.     (Norris,  loc.  cit.) 


Clavicle  united  by  ligamentous  bands. 


DELAYED    AXD    N'OX-UXIOX    OF    BROKEX    BOXES.  71 

but  the  observations  of  Sylvestre,  Brodie,  Beclard,  Home,  Howship, 
Otto,  Kulinholtz,  Houston,  Cooper,  Langenbeck  and  Brescbet  prove 
that  such  examples  are  occasionally  found.^ 

ISTorris  is  a  disciple  of  Dupuytren,  and  accepts  bis  doctrine  of  tbe 
formation  of  callus  without  reservation;  consequently  be  finds  no 
necessity  for  but  one  form  of  delayed  union,  namely,  that  which  we 
have  described  as  belongins;  to  tbe  first  class.  In  all  of  this  class  he 
assumes  the  existence  of  a  cartilaginous  ring  or  ferrule;  but  we  think 
the  error  of  this  exclusive  theor}^  has  been  sufficiently  shown  by  the 
observations  of  Paget  and  others,  and  we  should  be  warranted  there- 
fore in  affirming  the  existence  of  as  many  varieties  of  delayed  union 
as  there  are  varieties  in  the  manner  and  position  of  the  deposit  of  cal- 
lus, even  if  their  actual  existence  had  not  been  repeatedly  demon- 
strated by  dissections. 

The  causes  of  delayed  union  and  of  non-union,  are  either  constitu- 
tional or  local. 

The  constitutional  causes  are  chief! 3^  those  conditions  of  the  general 
system  which  manifest  themselves  by  anemia,  debility,  or  some  pecu- 
liar dyscrasy. 

Sanson,  Beulac,  Condie^  and  many  others  have  mentioned  cases  in 
which  the  existence  of  syphilis  in  the  system  has  seemed  to  prevent 
the  formation  of  callus;  but  on  the  other  hand  Lagneau  and  Oppen- 
heim^  incline  to  the  opinion  that  syphilis  exerts  in  this  respect  but 
little  influence;  and  even  Berard,  who  admits  the  pertinence  of  one 
case  observed  by  Nicod,  concludes,  after  numerous  researches,  that  it 
has  been  very  rarely  shown  to  affect  the  formation  of  callus."^ 

Pregnancy  and  lactation  have  been  known  to  interfere  with  the  union 
of  bones.  Werner,  Hildanus,  Wilson,  Hertodius,  Alanson,  Bard,  of 
New  York,  and  Condie,  of  Philadelphia,^  have  all  reported  examples, 
in  some  of  which  the  process  of  union  was  resumed  and  brought  to 
a  rapid  completion  so  soon  as  the  period  of  pregnancy  was  closed,  or 
when  lactation  ceased;  but  three  cases  reported  by  Sir  Stephen  Love 
Hammick,  would  seem  to  show,  what,  indeed,  other  evidences  render 
probable,  that  the  delay  was  less  due  to  the  fact  of  the  pregnancy  and 
the  lactation,  than  to  the  debility  occasionally  consequent  upon  these 
conditions.® 

As  to  the  question  whether  cancer  ever  causes  a  delay  in  the  union 

'  Nouvelles  de  la  Repub.  des  Lettres  de  Bayle,  p.  718,  ]685  ;  Lond.  Med.  Gaz.,  xiii. 
p.  57,  1833  ;  Beclard,  Gen.  Anat.,  trans,  by  Hayward,  pp.  149,  248  ;  Transac.  Med.-Cbir. 
Soc.  of  Edinburgh,  i.  p.  233,  1793  ;  Med.-Chir.  Trans.,  viii.  p.  517,  1817  ;  Otto's  Path. 
Anat.,  trans,  by  South,!,  p.  13S  ;  Journ.  Complement.,  ill.  p.  291  ;  Dub.  Med.  Jouru., 
viii.  p.  493  ;  Cooper  on  Frac.  and  Disloc  ,  fourth  London  ed.,p.  508 ;  Recherch.  sur  les 
Formation  du  Cal,  1819,  p.  34.     (Norris,  loc.  cit.) 

^  Diet,  de  Med.  et  Cliir.  Prat.,  iii.  p.  492  ;  Journ.  de  Med.  Chir.  et  Pharm.,  t.  xxv.  p. 
216.      (Noiris,  loc.  cit.) 

3  Expose  des  symp.  de  la  mal.  Ven.,  p.  525;  Oppenheim  on  False  Joints,  1837. 
(Norris,  loc.  cit.) 

♦  Op.  cit.,  p.  21. 

5  Cooper's  Die,  ed.  1838,  p.  546  ;  Opera  Hild.,  1681  ;  Wilson  on  the  Human 
Skeleton,  p.  214  ;  Bib.  Choisie  de  Med.,  xxiv.  p.  595  ;  Med.  Obs.  and  Inquiries,  4, 1772  ; 
Philosoph.  Trans  ,  xlvi.  p.  397,  1750.     (Xorris,  loc.  cit.) 

6  Practical  Remarks  on  Amputations,  Fractures,  kc,  p.  121.     (Norris,  loc.  cit.) 


72  DELAYED    AND    NON-UNION    OF    BROKEN    BONES. 

of  bones,  ISTorris  declares,  that  after  a  very  careful  examination  of 
what  has  been  written  upon  this  subject,  it  is  his  opinion  that  where 
the  fracture  arises  in  consequence  of  a  true  cancerous  deposit  around, 
or  in  the  interior  of  the  bones,  producing  absorption  of  their  tissue, 
no  union  takes  place ;  but  where,  as  is  usually  the  case,  the  fracture 
is  due  to  a  fragility  of  the  bones,  occasioned  by  what  Mr,  Curling 
has  denominated  eccentric  atrophy,  it  will  be  found  to  unite  readily. 
Parker,  of  New  York,  relates  the  case  of  a  girl  only  fifteen  years  of 
age,  in  whom  the  femur  was  broken  from  a  very  trivial  cause ;  and 
in  which  case  the  autopsy,  made  at  the  end  of  five  months  from 
the  time  of  the  accident,  furnished  some  confirmation  of  these  views. 
The  place  of  fracture  was  occupied  by  an  irregular  encephaloid  mass. 
It  is  curious,  however,  that  in  this  case,  the  callus  was  actually  formed 
at  first,  and  the  bone  seemed  to  be  well  united  at  the  end  of  five 
weeks  ;  but  at  the  time  of  the  autopsy  no  callus  existed.'' 

Scurvy,  fevers  of  a  low  type,  and  on  the  other  hand,  fevers  of  a 
highly  inflammatory  character,  profuse  uterine  and  vaginal  discharges, 
and  rachitis,  conduce  to  the  same  result. 

The  withdrawal  of  a  habitual  stimulus,  and  especially  a  change 
from  a  good  to  a  low  diet,  or  copious  bleedings,  may  either  of  them 
delay  the  deposit  of  ossific  matter  or  prevent  it  altogether.^ 

Bonn  has  furnished  two  cases  in  which  advanced  age  seemed  to 
have  retarded  the  formation  of  callus,  but  Horner  saw  a  fracture  of 
the  humerus  in  a  woman  ninety  years  old,  unite  in  five  weeks.^  I 
have  myself  noticed  a  good  many  similar  examples  in  advanced  life; 
and  it  is  now  rendered  quite  probable  that  surgeons  have  generally 
over-estimated  the  influence  of  age  upon  the  formation  of  callus. 

The  local  causes  are,  arrest  of  the  arterial  circulation,  paralysis  or 
impairment  of  the  nervous  circulation,  the  occurrence  of  the  fracture 
within  a  capsule,  obliquity  of  the  fracture,  overlapping  of  the  fragments, 
interposition  of  a  piece  of  bone,  of  a  tendon,  muscle,  or  of  a  clot  of 
blood,  or  separation  of  the  fragments  from  any  cause  whatever,  ery- 
sipelas, acute  phlegmonous  inflammation,  suppuration,  necrosis,  too 
much  motion,  compression,  exclusion  of  light  and  air  inducing  local 
scurvy,  wet  and  especially  cold  and  moist  dressings,  too  early  use  of 
the  limb,  &c. 

In  order  to  hasten  the  consolidation  when  it  is  simply  delayed,  we 
resort  to  all  of  those  expedients  which  are  calculated  to  invigorate  the 
general  system  ;  and  for  this  purpose  the  employment  of  a  nutritious 
diet  and  the  use  of  mineral  or  vegetable  tonics  may  not  be  properly 
omitted ;  but  in  our  experience  nothing  has  proved  so  efiicient  as  en- 
couraging the  patient  to  leave  his  bed  and  get  out  into  the  open  air ; 
for  which  purpose,  if  the  fracture  is  in  the  lower  extremities,  crutches 
will  be  necessary. 

As  local  means  we  may  enumerate  first  the  removal  of  those  local 
causes  which  seem  to  have  interfered  with  the  consolidation  or  with 
the  union.     If  the  fragments  have  been  oflQciously  disturbed,  it  may 

'  Parker,  New  York  Journ.  Med.,  July,  1852,  p.  97. 

^  NorriSj  loc.  cit.  ^  Ibid.,  p.  29. 


DELAYED    AND    NON-UNION    OF    BEOKEN    BONES.  73 

be  sufficient  to  impose  upon  the  limb  absolute  rest  for  a  certain  length 
of  time;  and  the  fragments  may  be  more  closely  pressed  against  each 
other;  in  other  cases  it  will  be  found  necessary  to  expose  the  limb  freely 
to  the  light  and  air  at  least  once  or  twice  daily,  and  to  rub  it  gently  with 
the  dry  hand  or  with  some  moderately  stimulating  oil,  so  as  to  induce 
a  more  healthy  condition  of  the  soft  parts,  and  encourage  the  natural 
circulation. 

Moving  the  fragments  freely  upon  each  other,  sufficient  to  deterrhine 
a  degree  of  excitement  in  the  adjacent  tissues,  and  upon  the  opposing 
surfaces  of  the  bones,  and  then  confining  them  during  one  or  two 
weeks  in  firm  and  well  fitting  splints,  will  often  succeed  when  other 
means  have  failed. 

Indeed  I  may  say  that  by  one  or  another  of  the  simple  methods 
now  enumerated  I  have  never  failed  sooner  or  later  to  effect  consolida- 
tion, in  recent  fractures ;  and  it  has  only  been  in  fractures  of  at  least 
four,  six,  or  eight  months'  standing  that  I  have  been  compelled  to  re- 
sort to  more  extreme  measures. 

As  a  means  of  combining  immobility  with  compression  and  health- 
ful exercise  the  "apparatus  immobile,"  in  many  of  its  forms,  is  pecu- 
liarly adapted.  White,  of  Manchester,  employed  a  firm  leather  sheath 
for  the  thigh.  H.  H.  Smith,  of  Philadelphia,  recommends  a  more 
complex  artificial  support,  upon  which  the  limb  may  be  allowed  to 
rest  while  in  the  act  of  progression.^  With  some  surgeons  the  object 
of  allowing  the  patient  to  walk  in  fractures  of  the  thigh  or  leg,  is 
chiefly  to  excite  in  the  tissues  adjacent  to  the  seat  of  fracture  some 
degree  of  inflammatory  action,  but  which,  as  the  result  in  one  of 
White's  patients  has  sufficiently  shown,  may  be  carried  too  far,  and 
even  determine  a  suppuration. 

Blisters,  mustard  cataplasms,  the  tincture  of  iodine,^  caustics,^  &c,, 
applied  externally  over  the  seat  of  fracture,  can  have  no  other  effect 
than  to  increase  moderately  the  congestion  of  the  tissues,  and  in  so 
far  they  may  aid  in  the  accomplishment  of  the  bony  union;  but  in 
this  respect  they  are  inferior  to  the  violent  twistings,  flexions,  and 
rubbings  of  the  broken  ends  of  which  we  have  already  spoken. 

Electricity  was  first  employed  by  Mr.  Birch,  of  London,  but  Dr. 
Mott  obtained  no  effect  from  it  in  two  cases  where  he  seems  to  have 
given  it  a  fair  trial.'*  Lente,  of  the  New  York  Hospital,  has  more  re- 
cently furnished  an  account  of  three  cases  treated  in  that  institution 
by  electricity  in  connection  with  acupuncturation  ;  the  mode  of  using 
which  was  to  pass  a  needle  down  to  the  periosteum  on  each  side  of 
the  bone,  and  to  attach  the  poles  of  the  battery  to  these  opposite  points. 
Lente  thinks  that  electricity  employed  in  this  way  is  much  more  effi- 
cient than  when  the  poles  are  merely  applied  to  the  surface.  He  in- 
forms us  also  that  other  cases  than  these  now  reported  have  been 
treated  successfully  in  this  hospital  by  means  of  electricity.^ 

'  H.  H.  Smith,  Amer.  Journ.  Med.  Sci.,  .Jan.  1855. 

2  Hartsliorne,  Eclectic  Rep.,  vol.  ill.  p.  114, 1813. 

^  Willoughby,  Am.  Journ.  Med.  Sci.,  Aug.  1834,  p.  444. 

*  Mott,  Med.  and  Surg.  Rep.,  p.  21,  p.  375. 

*  Lente,  New  York  Journ.  Med.,  Nov.  1850,  p.  317. 


74 


DELAYED  AND  NON-UNION  OF  BROKEN  BONES. 


Fig.  17. 


Mercury,  urged  to  ptyalism,  will  no  doubt  prove  serviceable  occa- 
sionally by  virtue  of  its  powers  as  an  anti-sypbilitic,  but  its  beneficial 
influence  in  other  cases  is  far  from  having  been  established. 

The  seton  is  said  to  have  been  first  suggested  by  Winslow,  in  1787  ; 
but  what  is  of  much  more  consequence,  the  credit  of  its  first  successful 
application  and  its  general  introduction  into  practice,  is  due  to  Dr. 
Philip  Syng  Physick,  of  Philadelphia,  by  whom  it  was  employed  in 
1802.' 

Physick  used  for  his  seton,  generally,  silk  ribbon,  or  French  tape ; 
and  this  he  introduced  by  means  of  a  long  seton  needle,  between  the 
ends  of  the  fragments.  He  recommended  that  the 
seton  should  remain  in  place  four  or  five  months, 
and  longer  if  necessary,  and  it  was  his  opinion 
that  the  failures  were  generally  due  to  its  being 
removed  too  early.  At  the  present  day,  however, 
surgeons  who  employ  the  seton  think  it  serves  its 
purpose  better  when  it  remains  in  place  but  a 
few  days,  not  longer,  perhaps,  than  ten  or  fifteen, 
always  taking  care  that  it  is  removed  before  ex- 
cessive suppuration  is  induced.  It  has  been  found 
especially  valuable  in  fractures  of  the  inferior 
maxilla,  clavicle,  and  upper  extremity  generally; 
but  in  the  case  of  the  femur,  it  has  so  frequently 
failed  that  Dr.  Physick  himself  did  not  recom- 
mend its  use.  ■ 

In  case  the  seton  cannot  be  passed  directly 
between  the  opposing  fragments,  as  recommended 
by  Physick,  we  may  adopt  the  practice  suggested 
by  Oppenheim,  and  carry  two  setons,  one  on  each 
side,  close  to  the  bone. 

Somme,  of  Antwerp,  preferred  a  loop  of  wire  to 

the  silk  seton  employed  by  Physick.^      Seerig 

passed   a  ligature  around  the  ligamentous  mass 

connecting  the  two  fragments,  and  then  proceeded 

to  tighten  the  ligature  until  it  fell  off?    Dr.  Hulse, 

of  the  U.  S.  Navy,  employed  stimulating  injections 

with  success  in  a  case  of  non-union,  accompanied 

with  an  external  and  fistulous  opening.^     In  1848, 

Dieffenbach    recommended  that    ivory  pegs    be 

introduced    into    holes    previously   made    in   the 

bone,*  by  means  of  a  gimlet  or  drill,  and  Mr. 

Stanley  has  succeeded  once  by  this  method.^ 

Malgaigne,  in  1837,  tried  to  introduce  acupuncture  needles  between 

the  ends  of  an  ununited  fracture,  but  although  he  thrust  the  needle 

down  to  the  bone  thirty-six  times,  he  was  unable  to  make  it  pass  once 


Physick's  first  case,  after 
28  years. 


'  Norris,  loc  cit.,  p.  46. 


'  Physick,  Med.  Repository  of  New  York,  vol.  i.  1804. 

^  Amer.  Journ.  Med.  Sci.,  vol.  vii.  p.  497. 

*  Hulse,  Amer.  Journ.  Med.  Sci.,  vol.  xiii.  p.  374. 

^  Malgaigne,  trans,  by  Packard,  op.  cit.,  p.  258,  note. 

^  Stanley,  New  York  Journ.  Med.,  Nov.  1854,  p.  441,  from  Dublin  Press. 


DELAYED    AND    NON-UXIOX    OF    BEOKEIST    BONES. 


75 


Fig.  18. 


between  the  ends  of  the  fragments.'  Wiesel  succeeded  better.  In  a 
case  of  ununited  fracture  of  the  ulna  of  nine  weeks'  standing,  hav- 
ing passed  two  needles  between  the  fragments, 
at  the  end  of  six  days,  the  needles  being  removed, 
consolidation  rapidly  ensued.^  This  practice 
does  not  differ  essentially  from  the  metallic  loop 
of  Somme.  It  is  only  a  modification  of  the 
seton. 

Brainard,  of  Chicago,  has  attempted  to  show 
that  setons  of  any  kind,  whether  of  wood,  ivory, 
or  metal,  placed  in  contact  with  tlie  bone,  occa- 
sion absorption,  caries,  and  necrosis,  but  that 
they  never  directly  give  rise  to  bony  callus ; 
and  that  the  occasional  success  of  the  seton,  which 
success  he  believes  to  have  been  greatly  exag- 
gerated, has  not  resulted  from  any  tendency  to 
favor  the  formation  of  callus,  but  from  the  indu- 
ration and  tenderness  of  the  soft  parts  produced 
by  it;  circumstances  which  by  conducing  to  rest, 
indirectly  favor  the  consolidation.'' 

In  May,  1848,  Miller,  of  Edinburgh,  reported 
five  cases  treated  successfully  by  subcutaneous 

puncture.  The  operation  consisted  in  passing  the  point  of  a  needle 
or  small  tenotomy  bistoury,  down  upon  the  ends  of  the  bone,  and  freely 
irritating  the  surfaces  at  several  points.'*  George  F.  Sandford,  of 
Davenport,  Iowa,  has  successfully  imitated  this  practice  in  two  cases.^ 

Brainard  employs  for  this  purpose  a  strong  metallic  perforator, 
consisting  of  a  handle  into  which  points  of  different  sizes  may  be  in- 
serted, and  which  have  been  hardened  so  as  to  penetrate  the  hardest 
bone  or  even  ivory  in  every  direction  easily.  The  points  are  "  some- 
what awl-shaped ;  but  more  pointed  in  the  middle  rather  than  like  a 
drill,  which  leaves  chips."     His  manner  of  using  this  instrument  is  as 


Dieffenbach's  drill  for  un- 
united fracture. 


Fig.  19. 


Brainard' s  perforator,  reduced  one-half. 


follows :  "  In  case  of  an  oblique  fracture,  or  one  with  overlapping,  the 
skin  is  perforated  with  the  instrument  at  such  a  point  as  to  enable  it 
to  be  carried  through  the  ends  of  the  fragments,  to  wound  their  sur- 
faces, and  to  transfix  whatever  tissue  may  be  placed  between  them. 


'  Malgaigne,  op.  clt. 

2  Wiesel,  Amer.  Journ.  Med.  Sci.,  vol.  xxxiv.  p.  254,  July,  1844. 

3  Brainard,  Trans.  Amer.  Med.  Assoc,  vol.  vii.,  1854:  Prize  Essay. 
*  Miller,  New  York  Journ.  Med.,  July,  1848,  p.  134. 

^  Sandford,  Trans.  Amer.  Med.  Assoc,  vol.  iii.  p.  355,  1850. 


76  DELAYED    AND    NON-UNION    OF    BROKEN    BONES. 

After  having  transfixed  them  in  one  direction,  it  is  withdrawn  from 
the  bone,  but  not  from  the  skin,  its  direction  changed,  and  another 
perforation  made,  and  this  operation  is  repeated  as  often  as  may  be 
desired."  Dr.  Brainard,  who  has  already  succeeded  by  this  procedure 
in  a  number  of  cases  of  ununited  fracture,  thinks  it  is  better  to  com- 
mence in  most  cases  with  not  more  than  two  or  three  perforations,  in 
order  that  the  effect  produced  shall  not  be  too  severe.  It  is  scarcely 
necessary  to  add  that,  after  the  punctures  have  been  made,  the  limb 
should  beput  completely  at  rest  in  appropriate  splints,  or  in  apparatus 
of  some  kind. 

Scraping  or  rasping  the  ends  of  the  bones  is  a  practice  which  dates 
from  a  very  early  period.  Mr.  Brodie  scraped  the  ends  of  the  bones, 
and  then  interposed  a  bit  of  lint.'  Mayor,  in  1828,  contrived  to  intro- 
duce an  iron,  previously  heated  in  boiling  water,  through  a  canula, 
and  thus  brought  the  heat  to  bear  directly  upon  the  ends  of  the  frag- 
ments; and  by  repeating  the  application  several  times  a  cure  was 
effected.^ 

Eesection  of  the  ends  of  the  bones,  first  brought  into  notice  by  White, 
of  Manchester,  in  1760,^  and  opposed  by  Brodie"  as  dangerous,  and 
by  Malgaigne  regarded  as  generally  useless  or  unnecessary,  has  still 
been  practised  a  great  number  of  times  with  more  or  less  success.  It 
is  especially  applicable  to  superficial  bones,  and  in  cases  where  the 
bones  overlap. 

Eoux  practised  resection  in  one  instance,  and  then  managed  to  en- 
gage the  point  of  one  of  the  fragments  in  the  medullary  canal  of  the 
other.'^ 

White,  of  Manchester,  Henry  Cliue,  of  London,  Hewson,  Barton, 
and  Norris,  of  Philadelphia,  have  applied  caustics  directly  to  the  ends 
of  the  fragments,  after  having  exposed  them  by  a  free  incision.^  Petit 
applied  the  actual  cautery.^ 

Tying  the  fragments  together  by  means  of  metallic  ligatures,  is  as 
old  as  the  days  of  Hippocrates ;  but  in  1805  Horeau  adopted  the  same 
procedure  in  a  case  of  ununited  fracture.**  J.  Kearney  Eodgers,  Mott 
and  Cheeseman,  of  New  York,  Flaubert,  of  Eouen,^  and  N.  E.  Smith, 
of  Baltimore,'°_  have  repeated  the  operation  with  complete  success. 
The  operation  is,  however,  not  without  its  hazards.  ISTorris  has  seen 
one  case  in  which  a  broken  patella  was  wired  together,  and  a  fatal 
result  followed  on  the  fourth  day. 

Finally,  having  thus  brought  rapidly  before  us  all  of  the  various 
modes  of  treatment  which  have  been  suggested  and  practised  for  non- 
union of  broken  bones,  we  are  prepared  to  affirm  the  following  con- 
clusions, or  summary  of  what  we  believe  ought  to  be  the  general 
course  of  procedure  in  these  cases  : — 

First.  Improve  the  condition  of  the  general  system. 

'  Brodie,  Lond.  Med.  Gaz.,  July,  1834.  2  Norris,  loc.  cit.,  p.  48. 

2  Diet,  de  Med.,  vol.  xiii.  p.  503. 

"  Brodie,  New  York  Jouru.  Med.,  vol.  viii.  1st  ser.,  p.  133. 

^  Norris,  loc.  cit.,  p.  49.  e  j^^jj^  7  j^^j^^  8  i]ji^^ 

3  Rodgers,  New  York  Journ.  Med.,  vol.  i.  1st  ser.,  p.  343,  1839. 
'°  Note  to  Packard's  Trans,  of  Malgaigue,  p.  255. 


BENDING    OF    THE    LONG    BONES.  77 

Second.  Eemove  as  far  as  possible  the  local  impediments,  sucli  as  a 
separation  of  the  fragments,  local  paralysis,  local  scurvy  resulting  from 
long  exclusion  from  light  and  air,  congestions,  &c. 

Third.  Increase  the  action  of  the  tissues  immediately  adjacent  to 
the  fracture,  upon  which  tissues  rather  than  upon  the  bone,  as  Mal- 
gaigne  thinks,  the  formation  of  callus  depends.  A  theory  which,  as 
applied  to  old  and  ununited  fractures,  we  are  not  prepared  to  deny. 
This  may  be  accomplished  by  frictions,  and  violent  flexions  of  the 
limb  at  the  seat  of  fracture ;  possibly  in  some  measure  by  the  applica- 
tion of  vesicants  or  of  other  stimulants,  to  the  skin  itself. 

Fourth.  Employ  again  compression  and  rest  for  a  period  of  from 
two  to  four  or  eight  weeks. 

Fifth.  Eesort  to  the  practice  recommended  by  Brainard,  namely, 
perforation  of  the  soft  parts  and  bone  with  an  awl. 

Sixth.  If  in  the  lower  extremity,  allow  the  patient  to  walk  about, 
after  the  plan  of  White  or  Smith. 

Seventh.  If  the  fracture  is  not  in  the  femur,  and  as  an  extreme 
measure,  employ  the  seton. 

Eighth.  Eesection  is  applicable  only  to  superficial  bones,  and  in 
cases  of  overlapping. 

Where  these  measures  have  failed,  after  a  fair  trial,  we  should  either 
abandon  the  case  as  hopeless,  only  supporting  the  limb  by  such  appa- 
ratus as  may  be  found  most  serviceable,  or  we  should  recommend 
amputation. 


CHAPTER    VII. 

BENDING,   PARTIAL   FRACTURES,  AND   FISSURES   OF 
THE  LONG  BONES. 

§  1.  Bending  of  the  Long  Bones. 

Strictly  speaking,  no  bone  can  be  much  bent  without  being  also 
more  or  less  broken,  and  that,  whether  it  immediately  and  spontane- 
ously resumes  its  position  or  not ;  for,  if  the  bending  and  straightening 
of  the  bone  be  repeated  a  sufficient  number  of  times,  the  yielding  of 
the  fibres  will  become  apparent,  and  at  length  the  separation  will  be 
complete.  The  first  of  this  series  of  flexions  was  quite  as  much  re- 
sponsible for  this  result  as  the  last,  and,  no  doubt,  performed  its  share 
in  the  production  of  the  complete  fracture. 

There  could  be  no  impropriety,  therefore,  in  speaking  of  a  bending 
of  the  bones  as  a  variety  of  incomplete  fractures,  as  I  have  done  in 


78  BENDING,   PARTIAL    FEACTUEES,   AND    FISSUEES. 

the  first  section  of  my  "  Eeport  on  Deformities  after  Fractures,"  made 
to  the  American  Medical  Association  in  1855.' 

They  have  been  called,  not  inappropriately,  interperiosteal  fractures, 
since  in  these  cases  the  periosteum  is  not  broken  ;  M.  Blandin  thinks 
that  the  outer  and  semi-cartilaginous  laminae  of  the  bone  also  do  not 
break,  while  the  deeper  laminge  suffer  an  actual  disruption.^  But  it 
is  quite  as  probable  that  in  a  majority  of  cases  the  true  pathological 
condition  is  a  compression  of  the  bony  fibres  upon  one  side,  with  a 
corresponding  expansion  upon  the  opposite  side,  with  only  a  slight 
interstitial  fracture,  too  trivial  to  be  easily  recognized  even  in  the  dis- 
section. Sometimes,  as  I  have  several  times  observed  in  my  experi- 
ments on  the  bones  of  chickens,  when  the  bones  are  small,  and  the 
bending  is  near  the  centre  of  the  shaft,  the  whole  of  the  laminae  on 
the  side  of  the  retiring  angle  produced  by  the  bending  are  doubled  in, 
or  indented  toward  the  hollow  of  the  bone,  so  that  the  fibres  on  the 
side  of  the  salient  angle  are  not  even  stretched,  and  much  less  broken. 
In  such  cases,  the  interstitial  disruption,  if  it  exists  at  all,  and  I  think 
it  does,  first  takes  place  in  the  deeper  layers  of  the  retiring  angle. 

I  might,  therefore,  feel  justified  in  continuing  to  call  these  cases 
partial  fractures,  or,  perhaps,  interstitial  fractures,  but  I  believe  that  the 
whole  subject  will  be  rendered  more  intelligible  if  I  call  them  simply 
bending  of  the  bones,  as  distinguished  from  those  other  and  more  pal- 
pably partial  fractures  of  which  I  shall  speak  presently. 

1.  Bending  ivith  an  immediate  and  spontaneous  restoration  of  the  bone 
to  its  Original  form. — The  possibility  of  this  accident,  to  which,  however, 
surgical  writers  have  hitherto  made  no  distinct  allusion,  is  rendered 
certain  by  the  following  experiments: — 

Experiment  1. — July  16,  1857.  I  bent  the  tibia  of  a  Shanghai 
chicken,  four  weeks  old,  at  about  the  middle  of  the  bone.  It  was  bent 
to  an  angle  of  quite  twenty-five  degrees,  but  it  was  not  felt  or  heard 
to  break.  It  immediately  and  spontaneously  resumed  the  straight 
position. 

July  18,  two  days  after  the  bending,  I  dissected  the  limb,  and  found 
no  trace  of  the  injury,  either  within  or  without  the  bone,  unless  I 
except  a  very  minute  blood-clot  in  the  centre  of  the  shaft. 

Experiment  2. — I  bent  the  leg  of  a  chicken,  four  weeks  old,  at  the 
same  point  and  to  the  same  degree.  It  immediately  resumed  the 
straight  position. 

Dissection  after  two  days.  Nothing  abnormal  except  a  small  blood- 
clot  in  the  centre  of  the  bone,  and  a  slight  disorganization  of  the 
medulla. 

Experiments  3  and  4. — Bent  both  legs  of  a  chicken,  four  weeks  old, 
at  the  same  point  and  in  the  same  manner.  They  immediately  resumed 
their  positions. 

Dissection  after  two  days.  No  lesions  or  morbid  appearances  which 
I  could  detect. 

'  Op.  cit.,  pp.  421-422. 

^  Markham's  Obs.  on  the  Surg.  Practice  of  Paris,  London  Med.-Chir.  Rev.,  vol. 
xxxiv.  p.  473,  1841. 


BENDING  OF  THE  LONG  BONES.  79 

Experiments  5  and  6. — Bent  botli  wings  of  a  chicken,  four  weeks 
old.  Bent  the  right  wing  to  an  angle  of  thirty-five  degrees.  I  did 
not  feel  them  break.     Both  resumed  their  positions  spontaneously. 

Dissection  after  two  days.     No  lesions  or  other  morbid  appearances. 

Experiment  7. — July  16, 1857, 1  bent  the  leg  of  a  Shanghai  chicken, 
five  weeks  old,  below  the  knee,  and  at  about  the  middle  of  the  bone. 
It  was  bent  to  an  angle  of  about  twenty-five  degrees,  but  the  bone  was 
not  felt  or  heard  to  break.  It  immediately  and  spontaneously  resumed 
the  straight  position. 

July  20,  four  days  after  the  bending,  I  dissected  the  leg,  but  could 
not  discover  the  slightest  trace  of  the  injury,  unless  it  be  that  there 
was  a  very  minute  ossific  deposit  in  the  centre  of  the  bone  at  the  point 
at  which  I  suppose  it  to  have  been  bent. 

Experiment  8. — July  16,  1857,  I  bent  the  right  leg  of  a  Shanghai 
chicken,  five  weeks  old,  at  the  same  point  as  in  the  first  experiment, 
and  to  the  same  extent.  The  bone  did  not  seem  to  break,  but  it 
immediately  and  spontaneously  resumed  the  straight  position. 

Dissection  after  four  days.  Nothing  appeared  to  indicate  the  seat 
of  the  bending  except  a  small  clot  of  blood  in  the  centre  of  the 
shaft. 

Experiment  9. — Bent  the  leg  of  a  chicken,  six  weeks  old,  in  the  same 
manner,  and  to  the  same  degree,  as  in  the  other  examples.  It  resumed 
its  position  spontaneously. 

Dissection  after  ten  days.  No  evidence  of  injury  of  any  kind;  the 
bone  being  sound  and  straight. 

These  experiments  were  made  in  connection  with  others,  which  I 
shall  take  occasion  hereafter  to  mention.  They  are  selected,  and  con- 
stitute the  whole  number  of  those  in  which  I  did  not  feel  the  bone 
break  or  crack  under  my  fingers.  In  every  instance  the  bone  sprung 
back  immediately  and  spontaneously  to  its  natural  form.  In  no  in- 
stance could  I  afterward  discover  any  trace  of  lesion,  or  sign  indicating 
the  point  at  which  the  bone  had  been  bent  before  dissection  ;  nor  did 
dissection  itself  disclose  anything  but  the  most  inconsiderable  marks, 
and  that  in  but  three  examples. 

I  infer,  therefore,  not  forgetting  the  caution  with  which  the  conclu- 
sions from  all  such  experiments  ought  to  be  applied  to  similar  acci- 
dents upon  the  human  skeleton,  that  whenever  the  bones  of  healthy 
infants  have  been  forcibly  bent,  they  will,  probably,  in  all  cases,  unless 
prevented  by  causes  foreign  to  the  bones  themselves,  spontaneously 
and  immediately  resume  their  position ;  and  that  no  sign  will  remain 
to  indicate  that  a  bending  has  occurred.  The  accident  will  not  be 
recognized;  and,  as  a  farther  inference,  this  bending  does  not  belong 
to  that  class  of  cases  which  have  been  so  frequently  described  as  ex- 
amples of  bending  without  fracture. 

2.  Bending  without  immediate  and  spontaneous  restoration  of  the  hone 
to  its  original  form. — "Dethleef,  believing  that  he  had  broken  the  two 
bones  of  the  leg  of  a  dog,  found  the  fibula  bent,  without  a  fracture. 
Similar  results  were  obtained  by  Duhamel  upon  a  lamb ;  by  Troja 
upon  a  pigeon ;  and  I  have  myself  twice  succeeded  in  bending  the 


80 


BENDING,   PARTIAL    FEACTURES,   AND    FISSUEES. 


fibula  while  breaking  the  tibia.  The  possibility  of  simple  curvature 
is  then  not  contestable"  (the  writer  means  to  say  that  the  possibility  of 
a  simple  curvature  remaining  permanently  bent,  is  not  contestable), 
"but  we  must  observe  that  they  have  never  been  obtained  except 
upon  young  animals,  and  that  they  have  been  unable  to  maintain  them- 
selves permanently  except  through  the  aid  of  a  fracture  and  displace- 
ment of  a  neighboring  bone ;  and  there  is  a  wide  difference  between 
these  and  those  pretended  curvatures  which  some  believe  they  have 
seen  in  man,  in  which  the  curved  bone  maintains  itself,  and  resists 
perfect  reduction  until  the  fracture  is  complete.'" 

In  this  single  paragraph  Malgaigne  seems  to  have  given  a  fair  sum- 
mary of  the  testimony  upon  this  point.  With  the  exception  of  these 
and  a  few  other  similar  examples,  some  of  which  I  think  I  have  ob- 
served myself,  where  one  of  the  bones  of  the  forearm  has  been  broken 
and  the  other  bent,  I  know  of  no  well  attested  cases  of  a  permanent 
bending;  using  the  term  bending  in  a  sense  distinguished  from  a  partial 
fracture. 

If,  in  numerous  cases  mentioned  by  surgical  writers,  there  has  seemed 
to  be  probable  evidence  that  the  permanent  bending  was  unaccompa- 
nied with  fracture,  there  has  always  been  wanting,  so  far  as  I  know, 
the  positive  evidence  of  dissection.  The  example  of  partial  fracture 
mentioned  by  Fergusson,  and  represented  by  a  drawing,  is  described 
as  having  also,  "toward  the  lower  extremity,  a  slight  indentation  and 
curve."^  This  was  the  radius  of  a  child ;  but  how 
long  the  child  survived  the  accident,  and  what  was  the 
condition  of  the  ulna,  we  are  not  informed.  The  ob- 
servations made  by  Jurine,  of  Geneva,  in  Switzerland,^ 
by  Barton"*  and  Norris,^  of  Philadelphia,  all  fail  to 
furnish  any  such  conclusive  evidence  of  the  correct- 
ness of  their  own  views.  Norris  says  that  "Thierry, 
of  Bordeaux,  Martin,  and  Chevalier,  had  all  met  with 
and  published  cases  of  this  kind  prior  to  the  appear- 
ance of  Jurine's  paper  (in  1810),  the  former  of  whom 
asserts  that  Haller,  in  experimenting  upon  the  subject, 
had  been  able  satisfactorily  to  produce  the  same  acci- 
dent in  young  animals."  For  myself,  I  cannot  say 
how  much  confidence  we  ought  to  place  in  these 
assertions  of  Thierry,  Martin,  and  Chevalier,  having 
never  seen  the  papers  referred  to ;  but  since  Dr.  Nor- 
ris  has  neglected  to  inform  us  whether  any  dissections 
were  ever  made,  we  shall  not  be  expected  to  regard 
their  testimony  as  conclusive. 

With  the  qualifications  now  made,  Gibson  was  more 
nearly  right  when  he  said,  "  Dupuytren  and  Dr.  John  Ehea  Barton 
have  each  furnished  accounts  of  bent  bones.  There  are  no  such  inju- 
ries, however,  in  my  opinion;  such  cases  being,  in  reality,  partial 

'  Traite  des  Frac,  etc. ;  par  L.  F.  Malgaigne,  torn.  i.  p.  48. 

2  Practical  Surgery;  by  Wm.  Fergusson,  4th  Am.  ed.,  p.  208. 

^  Journ.  de  Corvisart  et  Boyer.  torn.  xx.  p.  278,  etc. 

*  Phila.  Med.  Recorder,  1821.  '  ^  pj^iia.  Med.  Journ.,  vol.  xxix.  p.  233,  1842. 


Fig.  20. 


Case  mentioned  by 
Fergusson. 


i 


PARTIAL  FRACTURE  OF  THE  LONG  BONES.        81 

fractures,  from  which  deformities  result,  upon  the  same  principle  that 
a  piece  of  tough  wood,  like  oak  or  hickory,  if  broken  half  through, 
may  be  inclined  to  one  side  and  shortened,  although  still  held  together 
by  interlocking  of  fibres.  Many  specimens  in  my  cabinet,  and  in  the 
Wistar  Museum,  attest  the  accuracy  of  this  assertion,"^ 

In  my  own  experiments  upon  the  chicken,  the  bones  uniformly  re- 
sumed their  original  position  as  soon  as  the  restraining  force  was 
removed,  unless  a  fracture  occurred,  and  this  notwithstanding  the 
bones  were  bent  quite  abruptly  and  to  an  angle  of  twenty-five  de- 
grees. Certainly,  if  the  bones  of  children  may  be  bent  during  life  and 
be  made  to  retain  this  position  without  a  fracture,  then  the  same  thing 
might  be  done  upon  the  bones  of  children  recently  dead,  and  by  suc- 
cessful experiments,  this  long  agitated  question  might  be  easily  and 
forever  put  to  rest. 

It  will  be  understood  that  our  observations  are  confined  to  the  long 
bones.  That  the  flat' bones,  and  especially  the  bones  of  the  cranium, 
in  childhood,  may  be  indented  by  blows,  and  remain  in  this  condition, 
is  undeniable.  Scultetus  says  he  had  seen  "the  skull  pressed  down 
in  children,  without  a  fracture,  so  that  those  who  touch  or  look  upon 
it  can  perceive  a  small  pit,"^  and  it  has  been  mentioned  by  many  wri- 
ters since,  and  perhaps  before  his  day.  I  have  myself  published  two 
examples  of  it  in  the  second  volume  of  the  Buffalo  MedicalJournaU 


§  2.  Partial  Fracture  or  the  Long  Bones, 

1.  Partial  Fracture  with  immediate  and  spontaneous  restoration  of  the 
lone  to  its  original  form. — No  writer  seems  to  have  given  any  special 
attention  to  the  form  of  fracture  now  under  consideration  althouajh  its 
existence  appears  to  have  been  occasionally  recognized.  In  the  case 
reported  by  Camper,  in  1765,  of  a  partial  fracture  of  the  tibia,  the 
bone  had  regained  its  natural  form,  but  whether  immediately  after 
the  accident  occurred,  or  at  a  later  period,  I  am  not  able  to  learn.* 
Jurine,  Gulliver,  and  others,  have  noticed  a  gradual  straightening  of 
the  bone  after  a  partial  fracture,  so  that  its  complete  restoration  has 
been  accomplished  after  several  weeks  or  months ;  but  this,  although 
partly  due  to  the  same  cause  which  produces  occasionally  an  immediate 
restoration,  namely,  its  elasticity,  is  in  part  also  due  to  other  causes, 
and  will  be  more  properly  considered  under  the  next  division  of  par- 
tial fractures. 

Says  Malgaigne:  "Finally,  at  other  times  the  fracture  takes  place 
without  opening  and  without  curvature  ;  the  only  sign  which  one  can 
recognize  is  a  yielding  of  the  bone  under  the  pressure  of  the  finger,  at 
the  point  of  fracture ;  yet,  upon  the  living  subject,  we  may  see  the 

'  Institutes  and  Practice  of  Surgery,  by  Wm.  Gibson,  Pliila.,  1841,  vol.  i.  p.  254, 

^  The  Chirurgeon's  Storehouse,  by  Johannes  Scultetus,  1674,  p,  126. 

»  Op.  cit.,  p.  347,  1846,  Cases  1  and  2. 

■*  Essays  and  Obs.  Phys.  and  Lit.  of  Soc.  of  Edinburgh,  vol.  iii.  p.  537. 


82  BENDING-,   PAETIAL    FEACTUEES,   AND    FISSUEES. 

same  symptom  pertain  to  complete  and  simple  fractures  without  dis- 
placement."^ 

Blandin  has  described  the  accident  a  little  more  distinctly :  "  In 
some  cases  of  fracture  of  the  clavicle  occurring  about  the  middle  of 
the  bone  in  young  subjects,  displacement  of  the  fragments  does  not 
immediately  take  place,  thus  giving  rise  to  a  risk  of  an  error  in 
diagnosis,  by  which  the  ultimate  probability  of  a  cure  is  diminished. 
A  lad  seventeen  years  of  age,  was  recently  admitted  into  the  Hotel 
Dieu,  under  the  care  of  M.  Blandin,  having,  a  few  days  previously, 
fallen  upon  one  of  his  comrades  while  playing  with  him,  when  he 
instantly  experienced  pain  and  a  cracking  sensation  about  the  middle' 
of  the  left  clavicle,  where  there  soon  formed  a  tumor,  which,  increasing, 
induced  him  to  enter  the  hospital.  On  examination,  the  swelling  was 
found  to  occupy  the  middle  of  the  clavicle ;  it  was  about  as  large  as 
half  a  hen's  egg,  ovoid  in  shape,  well  circumscribed,  colorless,  and 
hard,  but  sensible  to  pressure.  There  was  not  any  deformity  of  the 
shoulder,  nor  any  abnormal  modification  of  the  axis  of  the  bone,  to 
indicate  the  existence  of  a  fracture ;  and  although  the  different  move- 
ments of  the  arm  caused  pain  in  the  shoulder,  yet  they  could  be  made 
without  much  difficulty. 

"  The  symptoms  in  this  case  would  lead  to  the  belief  that  it  was  a 
case  of  simple  periostitis,  caused  by  external  violence ;  but  M.  Blandin 
at  once  decided  that  there  existed  a  fracture  of  the  bone,  having  seen 
a  similar  case  previously  at  the  hospital  Beaujon,  where  the  tumor 
was  treated  as  traumatic  periostitis,  the  patient  merely  carrying  his 
arm  rn  a  sling,  until,  by  a  sudden  movement  of  the  limb,  displacement 
of  the  fragments  was  produced,  and  clearly  demonstrated  the  existence 
of  a  fracture.  A  second  case  occurring  soon  afterward,  M.  Blandin 
profited  by  the  experience  gained  from  the  preceding,  and  by  moving 
the  fragments  of  the  broken  clavicle  on. each  other,  obtained  motion 
and  crepitus.  Still  these  indications  were  not  so  clear,  that  M.  Mar- 
jolin  could  diagnosticate  a  fracture;  be  was  of  opinion  that  the  case 
was  one  of  exostosis,  probably  syphilitic,  and  the  crepitus,  he  believed, 
depended  on  an  erosion  of  the  osseous  surface.  In  consequence,  the 
patient  was  left  to  himself,  until  a  movement  of  the  arm  gave  proof  of 
the  fracture  by  the  displacement  of  the  broken  portions  of  the  bones. 

"Two  other  cases  occurring  in  young  subjects  have  been  admitted 
since  into  the  Hotel  Dieu,  under  the  care  of  M.  Blandin,  one  of  whom 
was  purposely  left  without  surgical  assistance,  while  Desault's  bandage 
was  applied  to  the  other.  The  former  soon  showed  evidences  of  con- 
secutive displacement;  the  latter  was  cured  without  any  deformity 
following. 

"The  surgeon  may  diagnose  a  fracture,  without  displacement  of  the 
middle  portion  of  the  clavicle,  when  a  circumscribed  tumor  forms  in 
that  part  in  young  subjects,  consecutive  on  a  fall  on  the  shoulder,  and 
motion  of  the  fragments,  with  crepitus,  can  be  detected,  there  not 
being  any  syphilitic  taint  in  the  constitution."-' 

'  Op.  cit.,  torn,  i.  p.  50. 

^  Am.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  473,  from  Journ.  de  Med.  et  Clnrurg.  Prat.,  July, 
1842. 


PARTIAL  FEACTURE  OF  THE  LOXG  BOXES.        83 

Prof.  Green,  of  Geneva  Med.  Col.,  X.  Y.,  has  furnished  me  the  fol- 
lowing account  of  a  case  which  came  under  his  observation. 

"December  21,  1847,  I  was  called  to  dress  what  was  considered  to 
be  a  fractured  clavicle,  of  George  Stone,  a  lad  eight  vears  of  age.  One 
of  his  playmates  had  tripped  him  in  such  a  manner  that  he  fell  on 
his  side,  striking  on  the  extremity  of  the  left  shoulder.  I  found  that 
he  was  unable  to  raise  the  hand  to  the  head.  On  examination,  I 
discovered  on  the  posterior  edge  of  the  clavicle,  at  the  inner  extremity 
of  the  external  curvature,  a  point  which  was  swollen,  tender,  and 
painful.  The  anterior  edge  of  the  clavicle  was  continuous,  and  there 
was  neither  crepitus  nor  displacement.  Considering  the  age  of  the 
patient,  and  the  appearance  of  the  parts,  I  diagnosed  bending  of  the 
clavicle  forward,  with  a  splitting  out  of  the  posterior  edge,  and  that  the 
bone,  by  its  elasticity,  had  resumed  its  ordinary  direction.  In  order 
to  be  safe,  however,  I  dressed  the  shoulder  as  for  actual  fracture  of 
the  clavicle,  lest  the  fracture  might  have  extended  nearly  through  the 
bone,  and  there  be  subsequent  displacement.  The  swelling  subsided 
in  four  or  five  days,  and  as  all  seemed  secure,  I  removed  the  dressings, 
and  heard  no  more  of  the  matter  until  the  11th  of  May,  ult.,  when  I 
was  called  to  see  the  patient  again,  and  found  that  he  had  met,  the  day 
before,  with  precisely  the  same  accident,  at  the  old  point,  and  by  the 
same  cause,  being  tripped  down  by  a  playmate.  This  time  the  swell- 
ing and  other  symptoms  of  inflammation  were  greater  than  before. 
The  anterior  edge  of  the  clavicle  was  entirely  continuous,  but  he  could 
not  raise  the  arm.  I  merely  directed  him  to  keep  to  his  bed  until  the 
swelling  and  inflammation  should  in  a  measure  subside.  In  three  or 
four  days  he  was  about.  The  callus  left  is  not  large,  still  it  is  quite 
evident." 

The  following  examples  which  have  come  under  my  own  observa- 
tion, will  illustrate  more  completely  their  usual  history  and  sj^mp- 
toms : — 

A.  B.,  aged  three  years,  fell  from  the  sofa  on  to  the  floor,  striking, 
it  is  thought,  on  her  right  shoulder.  Two  days  after  this,  she  fell 
again,  and  then,  for  the  first  time,  Mr.  B.  noticed  the  deformity.  She 
was  brought  to  me  three  days  after  the  second  fall.  There  existed 
then  a  round,  smooth  projection  at  the  outer  end  of  the  middle  third 
of  the  clavicle.  It  felt  hard,  like  bone.  The  line  of  the  clavicle  was 
not  changed.  I  advised  a  handkerchief  sling,  simply  to  steady  and 
support  the  arm.  Seven  months  after  the  accident,  she  fell  sick  and 
died.  The  projection  continued  at  the  time  of  death,  only  slightly 
diminished. 

H.  S.,  aged  six  years,  was  thrown  from  a  horse,  partially  breaking 
his  left  clavicle,  near  its  middle.  Dr.  Sprague,  of  Buffalo,  was  em- 
ployed. The  projection  in  front  was  for  several  days  very  apparent, 
and  was  examined  by  myself  at  Dr.  Sprague's  request.  The  bone  did 
not  seem  to  be  out  of  line.  Five  years  after  the  accident,  I  examined 
the  lad,  and  could  not  find  any  trace  of  the  original  injury. 

September  25,  1855.  Mrs.  T.  C.  brought  to  me  her  infant  child, 
then  but  two  weeks  old.  Upon  the  left  clavicle,  at  a  point  a  little 
nearer  the  acromion  than  the  sternum,  was  an  oblong  swelling,  three- 


84  BENDING,   PARTIAL    FRACTURES,   AND    FISSURES. 

quarters  of  an  incTi  in  length,  smooth  and  hard  like  callus;  the  skin 
was  not  reddened,  nor  tender.  There  was  no  motion  or  crepitus, 
and  the  line  of  the  axis  of  the  bone  was  perfect.  The  mother,  who 
had  been  put  to  bed  by  a  midwife,  thinks  the  injury  occurred  in  the 
act  of  birth,  although  she  did  not  notice  the  swelling  until  a  week 
after. 

October  20.  Nearly  one  month  later,  I  found  no  change  in  the  con- 
dition of  the  bone ;  the  hard  lump  remained,  but  it  was  still  entirely 
free  from  tenderness.     I  have  not  seen  the  child  since. 

An  infant  boy,  three  years  old,  fell,  August  12,  1857,  from  the  hands 
of  the  nurse.  The  child  cried,  but  the  point  of  injury  was  not  de- 
tected until  the  third  or  fourth  day,  although  the  mother  examined  the 
shoulders  and  neck  carefully  at  the  time.  She  is  quite  certain  that  if 
any  swelling  or  discoloration  had  been  present  she  would  have  seen 
it  then,  or  on  the  subsequent  days,  while  washing  and  dressing  the 
child ;  when  first  seen  it  was  very  distinct,  but  not  so  large  as  at  pre- 
sent. 

August  19.  The  child  was  brought  to  me.  A  little  to  the  sternal 
side  of  the  middle  of  the  right  clavicle  there  was  an  oblong  node-like 
swelling,  of  the  size  of  the  half  of  a  pigeon's  egg,  hard,  smooth,  and 
feeling  like  bone;  there  was  no  discoloration  or  swelling  of  the  integu- 
ments; no  crepitus  or  motion;  the  line  of  the  clavicle  seemed  nearly 
or  quite  unchanged. 

I  have  not  noticed  this  variety  of  accident  in  any  other  bone  except 
the  clavicle,  yet  it  is  not  improbable  that  it  happens  occasionally,  and 
perhaps  quite  as  often,  in  other  long  bones,  but  that  its  existence  is 
not  elsewhere  so  easily  recognized. 

Of  eighty-nine  fractures  of  the  clavicle,  which  have  come  under  my 
observation,  twenty-one  were  partial  fractures;  and  of  these  six  were 
spontaneously  and  immediately  restored  to  their  natural  axes. 

Experiment. — In  fourteen  experiments  upon  the  bones  of  chickens, 
a  partial  fracture,  with  immediate  and  spontaneous  restoration,  has 
occurred  but  once.  In  nine  of  these  cases  the  bones  were  only  bent, 
and  in  five  they  were  partially  broken ;  an  immediate  restoration  has 
occurred,  therefore,  in  one  case  out  of  five  of  partial  fracture;  while 
in  my  reported  examples  of  partial  fracture  of  the  clavicle  it  has  been 
noticed  about  once  in  every  four  cases.  The  following  is  the  experi- 
ment to  which  I  have  referred : — 

I  produced  a  partial  fracture  of  the  tibia  in  a  chicken  six  weeks  old. 
The  fracture  was  near  the  middle  of  the  bone.  I  felt  it  break  under 
my  finger;  but  on  removing  the  pressure,  it  immediately  and  spon- 
taneously resumed  the  straight  position. 

I  dissected  the  limb  on  the  tenth  day.  The  line  of  the  axis  of  the 
bone  was  perfect ;  but  on  the  fractured  side  was  a  node-like  enlarge- 
ment, sufficient  to  be  distinctly  felt  and  seen  before  the  soft  parts  were 
removed. 

Pathology. — In  no  case,  except  in  my  single  experiment  upon  the 
bone  of  a  chicken,  has  the  actual  condition  been  determined  by  di^?- 
section,  and  if  any  question  has  existed  heretofore  as  to  the  possibility 
of  an  immediate  and  spontaneous  restoration  after  a  partial  fracture, 


PAETIAL  FRACTURE  OF  THE  LONG  BOXES.        80 

this  experiment  ought  to  decide  it  in  the  affirmative;  but  then  the  first 
nine  experiments  already  quoted  have  shown  that  a  mere  bending  with 
immediate  restoration  leaves  no  such  traces  or  signs  as  have  been  de- 
scribed as  following  these  accidents.  We  have,  therefore,  the  negative 
argument  that,  since  a  bending  with  restoration  leaves  no  signs,  these 
examples  reported  by  myself  and  others  as  having  occurred,  and  as 
having  been  followed  by  a  node-like  swelling,  etc.,  must  have  been 
partial  fractures.  ^Moreover,  in  one  of  the  cases  reported  by  Blandin, 
there  was  a  feeble  crepitus;  and  in  another,  the  subsequent  displace- 
ment proved  the  correctness  of  his  diagnosis. 

We  conclude,  then,  that  these  are  examples  of  partial  fracture,  but 
that  the  number  of  bony  fibres  which  have  given  way  is  too  incon- 
siderable, as  compared  with  those  not  broken,  to  affect  materially  the 
elasticity  of  the  bone. 

Diagnosis. — The  diagnosis  will  depend  somewhat  upon  the  history 
of  the  accident  as  well  as  upon  the  present  symptoms.  In  no  instance, 
where  I  could  ascertain  the  cause,  have  I  known  an  incomplete  frac- 
ture of  this  variety  produced  by  any  other  than  an  indirect  blow ;  and 
where  the  clavicle  has  been  the  seat  of  the  curvature  the  counter-blow 
has  been  received  upon  the  end  of  the  shoulder.  This  fact  possesses, 
therefore,  equal  significance  in  its  relation  to  either  of  the  varieties  of 
partial  fracture ;  but  in  the  case  of  a  partial  fracture,  with  a  permanent 
curvature,  the  diagnosis  would  be  complete  without  the  history,  while 
in  this  case  it  might  not  be,  and  a  knowledge  of  the  manner  in  which 
the  accident  occurred  would,  therefore,  be  of  great  importance. 

The  signs,  then,  after  a  knowledge  of  the  fact  that  a  blow  has  been 
received  upon  the  shoulder,  are  a  node-like  swelling  upon  the  anterior 
or  upper  face  of  the  clavicle,  generally  in  its  middle  third,  this  swell- 
ing being  hard,  smooth,  oblong;  the  skin  only  slightly  or  not  at  all 
swollen  or  tender,  and  in  no  way  discolored,  as  it  would  have  been 
had  the  swelling  upon  the  bone  been  the  result  of  a  direct  blow,  and 
the  line  of  the  axis  of  the  bone  unchanged.  I  have  never  detected 
motion  or  crepitus  at  the  point  of  injury,  yet  we  have  seen  that  Blan- 
din was  able  to  detect  both  in  one  instance ;  nor  has  it  ever  occurred 
to  me  to  see  the  swelling  upon  the  bone  until  two  or  three  days  after 
the  injury  was  received.  We  are  not  likely,  therefore,  to  recognize 
this  accident  immediately  after  its  occurrence. 

Treatment. — In  the  case  of  the  clavicle,  neither  bandages,  slings, 
compresses,  nor  lotions  can  be  of  much  service.  The  utmost  that  can 
be  necessary  is  to  enjoin  some  degree  of  care  in  using  the  arm  of  the 
injured  side.  The  consolidation  will  be  speedily  accomplished,  and 
after  a  time  the  ensheathing  callus  will  wholly  disappear. 

If  a  similar  accident  should  occur  in  any  other  of  the  long  bones, 
as  retentive  and  precautionary  means,  splints  might  be  applied,  at 
least  for  a  few  days. 

2.  Partial  Fracture  vjiihout  immediate  and  spontaneous  restoration  of  the 
lone  to  its  natural  form. — The  causes  of  this  accident  are  the  same  with 
those  which  produce  simple  bending,  or  partial  fracture  with  imme- 
diate and  spontaneous  restoration,  from  which  latter  they  differ  pro- 


BENDING,   PARTIAL    FRACTURES,   AND    FISSURES. 


bably  in  the  greater  extent  of  the  bony  lesion.     Perhaps,  also,  they 
differ  sometimes  in  the  peculiar  form  and  degree  of  the  denticulation 
at  the  seat  of  the  fracture ;  in  consequence  of  which  an 
Fig.  21.         antagonism  of  the  fibres  takes  place,  preventing  a  resto- 
ration of  the  bone  to  its  original  form. 

They  constitute  a  large  majority  of  those  examples  of 
partial  fractures  which  come  under  our  observation  in 
the  various  long  bones.  In  eighty-nine  fractures  of  the 
clavicle,  it  has  been  observed  by  me  fifteen  times,  or 
once  in  about  every  six  cases.  In  one  hundred  and 
eighty-eight  fractures  of  the  radius  and  ulna,  it  has  oc- 
curred twelve  times,  or  once  in  about  fifteen  cases.  The 
following  are  the  exact  observations  upon  which  this 
latter  statement  rests : — 

Fractures  of  the  radius  alone,  fifty-four;  no  partial 
fractures. 

Fractures  of  the  ulna  alone,  thirty;  no  partial  fractures. 
Fractures  of  both  bones  at  once,  fifty-two  (one  hundred 
and  four  fractures) ;  twelve  partial  fractures. 

The  one  hundred  and  four  fractures  last  enumerated 
were  as  follows : — 

Eadius  and  ulna  both  partially  broken  five  times ;  ten 
partial  fractures. 

Radius  partially  broken  and  ulna  completely,  once. 

Ulna  partially  broken  and  radius  completely,  once. 

It  has  not  happened  to  me  to  meet  with  this  fracture 

in  any  other  bone;  but  examples  have  been  mentioned 

as  having  occurred  in  the  humerus,  ribs,  femur,  tibia, 

and  fibula. 

Very  few  surgeons  have  spoken  of  partial  fractures  in 
the  clavicle,  while  Jurine,  Symes,  Liston,  Miller,  Norris, 
and  many  others,  have  declared  that  it  is  much  more  frequent  in  the 

bones  of  the  forearm  than  else- 
where. This  does  not  agree 
with  my  experience,  according 
to  which  it  occurs  oftener  in  the 
clavicle  than  in  the  forearm:  a 
discrepancy  which  I  cannot  very 
well  explain,  except  by  supposing 
that,  in  the  case  of  the  clavicle, 
the  accident  has  either  been  over- 
looked entirely  or  misapprehend- 
ed. Blandin,  who  we  have  seen 
has  reported  five  cases  of  partial 
fracture  of  the  clavicle  with  im- 
mediate restoration,  states  dis- 
tinctly that  in  two  of  these  cases 
distinguished  surgeons  of  Hopital 
Beaujon  and  Hotel  Dieu  failed  to 
recognize  it. 


Partial  fracture  of  the  clavicle  without  spontane- 
ous restoration.  From  nature ;  taken  three  weeks 
after  the  accident. 


Partial  fracture 
without  restora- 
tion of  the  hone 
to  its  natural 
form. 


PARTIAL  FRACTURE  OF  THE  LONG  BONES.        87 

Says  Turner :  "  The  next  I  shall  descend  to  is  that  of  the  clavicle, 
or  collar-bone,  which  I  have  found  the  most  frequently  overlooked,  I 
think,  of  any  other,  till  it  has  been  sometimes  too  late  to  remedy, 
especially  among  the  children  of  poor  people ;  for,  though  they  find 
these  little  ones  to  wince,  scream,  or  cry,  upon  the  taking  off  or 
putting  on  their  clothes,  yet,  seeing  that  they  suffer  the  haudling  of 
their  wrists  and  arms,  though  it  be  with  pain,  they  suspect  only  some 
sprain  or  wrench,  that  will  go  away  of  itself,  without  regarding  any- 
thing further  or  looking  out  for  help ;  whereas,  this  fracture  discovers 
itself  as  easily  as  most  others.  For  not  only  the  eye,  in  examining 
or  taking  a  view  of  the  part,  may  plainly  perceive  a  bunching  out  or 
protuberance  of  the  bones  when  the  neck  is  bared  for  that  purpose, 
with  a  sinking  down  in  the  middle  or  on  one  side  thereof,  which  will 
be  still  more  obvious  on  comparing  it  with  its  fellow  on  t^e  other 
side ;  but  when  it  is  more  obscure,  and  the  bone,  as  it  were,  cracked 
only — a  semi-fracture^  as  we  say — yet,  by  pressing  hard  upon  the  part, 
from  one  extremity  to  the  other,  you  will  find  your  patient  crying 
out  when  you  come  upon  the  place;  and  by  your  fingers,  so  examin- 
ing, sometimes  perceive  a  sinking  farther  down,  with  a  crackling  of 
the  bone  itself."^ 

Erichsen,  who  regards  all  of  these  cases  as  mere  bendings  of  the 
bones,  remarks  that  it  "  most  commonly  occurs  in  the  long  bones, 
especially  the  clavicle,  the  radius,  and  the  femur."^  He  says,  more- 
over, "  fracture  of  the  clavicle  in  infants  not  unfrequently  occurs,  and 
is  apt  to  be  overlooked.  The  child  cries  and  suffers  pain  whenever 
the  arm  is  moved.  On  examination,  an  irregularity,  with  some  protu- 
berance, will  be  felt  about  the  centre  of  the  bone."^  The  reader  will 
not  fail  to  recognize,  in  these  symptoms,  the  incomplete  fracture  of 
which  we  are  now  speaking,  although  Erichsen  evidently  believes 
them  to  be  examples  of  complete  fracture. 

In  addition  to  this  testimony  as  to  the  frequency  of  these  fractures 
in  the  clavicle,  I  will  only  mention  that  Johnson,  in  his  review  of 
Markham's  Observations  on  the  Surgical  Practice  of  Paris,  says  that 
"  many  surgeons  have  noticed  the  incomplete  fracture  of  the  clavicle 
as  of  other  bones,  which  take  place  in  the  young."'' 

Pathology. — The  following  experiments  will  assist  in  the  elucidation 
of  this  point  of  our  subject : — 

Experiment  1, — I  bent  the  leg  of  a  chicken  five  weeks  old.  It  cracked 
under  my  fingers,  and  remained  bent.  Having  waited  a  few  seconds, 
and  finding  that  it  was  not  restored  to  position,  I  pressed  upon  it  and 
made  it  straight.     The  chicken  walked  off"  without  any  limp. 

On  the  fourth  day,  before  dissection,  the  bone  looked  as  if  it  was 
still  bent ;  but  on  removing  the  soft  parts,  the  line  of  the  axis  of  the 
bone  was  found  to  be  straight.  The  areolar  tissue  under  the  skin  was 
infiltrated  with  lymph,  which  was  most  abundant  near  the  fracture, 
and  gradually  diminished  toward  each  extremity  of  the  limb.     This 

'  Art  of  Surgery,  by  Daniel  Turner,  London,  1742,  voL  ii.  p.  255. 

2  Science  and  Art  of  Surgery.     Phila.  ed.,  1854,  p.  180. 

3  Ibid.,  p.  205.  "  Lond,  Med.-Cbir.  Rev.,  vol.  xxxiv.  p.  474,  1841. 


88 


BENDING,    PAETIAL    FEACTUEES,    AND    FISSUEES, 


effusion  was  confined  almost  entirely  to  the  front  of  the  limb,  or  to 
that  side  which  had  been  broken,  and  constituted  the  greater  part  of 
the  enlargement  which  I  had  noticed  before  the  dissection  was  com- 
menced, and  which  then  felt  like  bone. 

On  the  front  of  the  bone,  also,  underneath  the  periosteum,  there  was 
a  loose,  honey-comb  deposit  of  ensheathing  callus,  about  one  line  in 
thickness,  and  extending  upward  and  downward  about  half  an  inch. 
This  callus  surrounded  the  bone  in  three-fourths  of  its  circumference; 
but  there  was  no  callus  on  its  posterior  surface.  It  was  also  deficient 
exactly  along  the  line  of  fracture,  in  front  and  on  the  sides,  in  conse- 
quence of  which  an  oblique  groove  remained,  indicating  the  seat  of 
the  fracture. 

Experiment  2. — I  produced  a  partial  fracture  at  the  same  point,  in  a 
chicken  five  weeks  old.     The  bone  was  felt  to  crack,  and,  as  it  would 
not  straighten  spontaneously,  I  immediately  bent  it  back  to  its  place. 
On  the  eighth  day  I  dissected  the  limb.     The  appearances,  before 
and  after  dissection,  were  the  same  as  in  Experiment  1,     No  ensheath- 
ing callus  on  the  posterior  surface.     The  furrow  over  the 
Fig,  23.      line  of  fracture  was  not  quite  so  deep  as  in  Experiment  1, 
On  opening  into  the  centre  of  the  shaft  I  found  the  canal 
nearly  filled  with  bony  matter  opposite  the  fracture,  and 
the  broken  ends  were  completely  united. 

Experiment  8. — This  was  made  upon  the  opposite  leg  of 
the  same  chicken,  and  with  the  same  results, 

Expieriment  4, — Same  as  experiment  1,  except  that  I 
supposed  at  first  the  bone  was  broken  completely  off. 
The  dissection  showed,  however,  that  such  was  not  the 
fact.  The  posterior  wall  was  a  little  thickened,  but  the 
ensheathing  callus  was  only  in  front  and  on  the  two  sides. 
The  medullary  canal  was  closed  with  bone. 

So  early  as  the  year  1673,  a  dissection  made  by  Glaser, 
demonstrated  incontestably  the  existence  of  partial  frac- 
tures in  the  shaft,  and  in  the  direction  of  the  diameter  of 
long  bones,^  Camper,  in  1765,  again  described  a  specimen 
which  he  had  seen  f  and  Bonn,  in  1783,  added  a  third 
positive  observation,^ 

M,  Gimele  is,  therefore,  in  error  when  he  ascribes  to 
Gampaignac  the  credit  of  having  first  proven  by  dissection 
their  existence,  in  a  paper  communicated  to  the  Academy 
of  Medicine  at  Paris,  in  1826.  Gampaignac,  however, 
seems  to  have  been  the  first  who  described  very  particu- 
larly the  condition  of  this  fracture.  He  has  recorded  the 
history  and  dissection  of  two  cases,  one  of  which  occurred 
in  the  fibula,  and  one  in  the  tibia.    The  first  of  these  cases 

Partial  fracture  -lii  iii  •        ^    ^^  •  i       i. 

afterunioniscon- '^^^  ^  S^'^^  twclvc  ycars  Old,  who  survivcd  the  acciQent 
summated.  just  eight  wccks.      The  fracture  had  occurred  near  the 

'  Malgaigne,  op,  cit,,  p.  44,  from  Th.  Boneti  Sepulchretum,  1700,  torn,  iii.  p.  424. 

2  Essays  and  Obs,  Pliys,  and  Lit.  of  Soc,  of  Edinburgh,  1771,  vol.  iii.  p.  537, 

3  Malgaigne,  op,  cit,,  p.  44,  from  Descript,  Thes,  Ossium  Morb,  Hoviani,  1783. 


PAETIAL  FEACTUEE  OF  THE  LONG  BONES.        89 

middle  of  the  bone,  and  upon  the  anterior  and  internal  side;  in  which 
direction,  resting  against  the  tibia,  the  bone  was  found  inclined.  "  The 
bony  fibres  had  been  broken  at  different  lengths,  almost  exactly  like 
what  takes  place  in  the  branch  of  a  tree  which  has  been  partially 
broken ;  and,  as  we  see  sometimes  in  this  latter  case,  the  bundles  of 
splintered  bony  fibres  abutted  upon  themselves,  and  did  not  take  their 
places  when  we  endeavored  to  restore  them ;  so  the  abnormal  angle 
which  the  fibula  represented  could  not  be  effaced,  the  ends  of  the 
divided  fasciculi  not  restoring  themselves  to  their  respective  places. 
This  disposition  might  be  especially  seen  toward  the  anterior  part  of 
the  internal  face,  where  a  packet  of  fibres,  coming  from  below,  was 
braced  against  the  upper  lip  of  the  division,  which  it  thus  held  open. 
This  opening  at  first  made  me  think  that  the  fragments  could  not  have 
been  well  consolidated ;  but  I  assured  myself  that  it  was,  and  the 
fact  was  subsequently  confirmed  by  the  Academy  of  Medicine ;  all 
the  points  which  were  in  contact  were  found  intimately  united.'" 

Diagnosis. — The  diagnosis  is  not  difficult.  The  distortion  indicates 
sufficiently  the  existence  of  a  fracture,  while  the  complete  absence  of 
crepitus  in  nearly  all  cases,  and  of  either  overlapping  or  lateral  dis- 
placements, must,  generally,  especially  where  the  accident  has  occurred 
in  a  child,  sufficiently  indicate  that  the  fracture  is  incomplete.  It  will 
assist  the  diagnosis  also  to  notice  that  these  accidents  are  almost  con- 
fined to  the  middle  third  of  the  long  bones ;  and  they  are  produced 
usually  by  a  bending  of  the  bones,  the  forces  operating  upon  the 
extremities,  and  not  directly  upon  the  point  which  is  broken. 

In  complete  fractures,  also,  preternatural  mobility  is  so  constant  a 
sign  as  to  be  regarded  as  diagnostic,  while  here  there  is  almost  always 
a  great  degree  of  immobility  at  the  seat  of  fracture.  The  angle  made 
by  the  projecting  extremities  is  usually  rather  gentle  and  smooth; 
at  other  times  it  is  abrupt,  indicating  a  greater  amount  of  fracture,  or 
that  the  outer  fibres  are  broken  more  irregularly.  The  power  of  using 
the  limb  is  generally  sensibly  impaired,  but  not  completely  lost. 

Treatment. — Jurine,  Murat,  Campaignac,  Gulliver,  Malgaigne,  with 
some  others,  have  noticed  the  fact  that  it  is  often  difficult,  and  some- 
times quite  impossible,  to  restore  these  bones  to  position ;  a  cir- 
cumstance which  they  have  justly  ascribed  to  that  condition  of  the 
fragments  described  by  Campaignac.  The  broken  extremities  of  the 
fasciculi  become  braced  against  each  other,  and  effectually  resist  all 
efforts  to  straighten  the  bone ;  unless,  indeed,  so  much  force  is  used 
as  to  render  the  fracture  complete ;  a  result  which,  if  it  should  chance 
to  happen,  need  not  occasion  any  alarm,  since,  while  it  enables  us  at 
once  to  restore  the  bone  to  line,  does  not  much  increase  the  danger 
of  lateral  displacement  and  overlapping.  That  the  fracture  has  be- 
come complete  we  may  know  by  a  sudden  sensation  of  cracking,  by 
the  increased  mobility,  and  by  the  crepitus  which  is  now  easily  deve- 
loped. 

But  we  need  not,  on  the  other  hand,  be  over  anxious  to  straighten 

'  Des  Fractures  Incompletes  et  des  Fractures  Longitudinales  des  Os  des  Membres  ; 
par  J.  A.  J.  Campaignac.     Paris,  1829,  pp.  9-10. 


90  BENDING,   PARTIAL    FRACTURES,   AND    FISSURES. 

the  bone  completely,  since  experience  has  shown  that  after  the  lapse 
of  a  few  weeks  or  months  the  natural  form  is  usually  restored  spon- 
taneously, I  am  not  now  speaking  of  those  cases  in  which  the  resto- 
ration occurs  immediately,  where  it  is  probable  that  the  splintered 
fibres  offer  no  resistance  to  the  restoration ;  but  only  of  those  in  which 
the  bone  straightens  so  gradually  as  to  induce  a  belief  that  the  broken 
ends  are  the  cause  of  the  resistance.  To  this  variety  of  accident  belong 
cases  one,  five,  six,  seven,  and  eight,  published  in  my  Report  on  De- 
formities after  Fractures;'  in  one  of  which  the  natural  axis  was  resumed 
in  less  than  four  weeks.  In  a  case  mentioned  by  Gulliver,  it  required 
about  the  same  time  to  render  the  bones  of  the  forearm  perfectly 
straight;  and  in  one  case  mentioned  by  Jurine,  at  the  end  of  six 
months  it  was  "difficult  to  say  which  arm  had  been  broken,  and  at 
the  end  of  one  year  it  was  impossible." 

Jurine  attributes  this  restoration  to  "  muscular  action,  or  more 
especially  to  the  reaction  of  the  compressed  bony  plates ;"  but  while 
it  is  easy  to  understand  how  the  reaction  of  the  compressed  fibres 
may  accomplish  the  gradual  restoration,  I  am  unable  to  understand  in 
what  manner  muscular  action  contributes  to  this  result,  since  most  of 
the  muscles  attached  to  the  long  bones  operate  so  much  more  ener- 
getically in  the  direction  of  their  axis  than  in  the  direction  of  their 
diameters.  Indeed,  we  have  often  seen  these  bones  bent  after  com- 
plete fractures,  and  before  the  union  was  consummated,  by  muscular 
action  alone. 

I  repeat,  then,  that  the  gradual  restoration  of  these  bones  is  due  to 
the  same  circumstance  which  produces  at  other  times  an  immediate 
restoration,  namely,  the  elasticity  of  the  unbroken  fibres,  but  which 
elasticity,  in  this  latter  instance,  is,  for  a  time,  effectually  resisted  by 
the  bracing  of  the  broken  fibres.  At  length,  however,  in  consequence 
of  the  gradual  absorption  of  the  broken  ends,  this  resistance  is  removed, 
and  the  bone  becomes  straight.  If  this  absorption  refuses  to  take 
place,  and  the  fibres  continue  pressed  forcibly  against  each  other,  as 
in  the  case  described  by  Campaignac,  then  the  bone  remains  perma- 
nently bent. 

Having  straightened  the  bone  as  far  as  is  practicable,  it  only  remains 
to  secure  the  fragments  in  place  by  suitable  bandages  or  splints.  If 
the  restoration  is  incomplete,  these  means  may  assist  the  efforts  of 
nature  in  accomplishing  a  gradual  restoration. 

It  is  scarcely  necessary  to  say  that  extension  and  counter-extension 
avail  nothing  in  partial  fractures. 


§  3.  Fissures. 

These  constitute  the  second  principal  form  of  incomplete  fractures, 
or  those  in  which  the  fracture  is  accompanied  with  no  appreciable 
bending,  which  occur  almost  exclusively  in  inflexible  bones,  such  as 
the  compact  bones  of  adults,  and  more  often  in  the  direction  of  their 

'  Trans.  Am.  Med.  Assoc,  vol.  viii.,  1855,  pp.  392-5. 


FISSURES.  91 

axes  than  of  their  diameters.  They  are  complete  so  far  as  they  extend, 
but  they  do  not  completely  sever  the  bone  so  as  to  form  two  distinct 
fragments.  They  have  been  most  frequently  observed  in  the  flat 
bones,  such  as  the  bones  of  the  skull,  and  in  the  upper  bones  of  the 
face ;  occasionally  in  the  long  bones,  both  in  their  diaphyses  and  epi- 
physes, and  rarely  in  the  short  bones. 

M.  Gariel  has  reported,  in  the  Bulletins  de  la  Societe.  Anat.,  for  1835, 
a  case  of  fissure  of  the  inferior  maxilla,  occurrins:  in  a  lad  sixteen  or 
eighteen  years  old.  Paletta  found  a  fissure  extending  partly  through 
the  third  dorsal  vertebra,  in  a  man  who  had  fallen  upon  his  back 
eleven  days  before ;  and  M.  Lisfranc  has  mentioned  a  remarkable  case 
of  fissure  and  partial  fracture,  with  bending  of  five  ribs  in  the  same 
person.^  Malgaigne  believes  that  he  has  seen  one  example  of  this 
variety  of  incomplete  fracture  of  the  scapula,  occurring  through  a 
portion  of  the  infra-spinous  region.  I  have  myself  elsewhere  recorded 
another,  as  having  been  found  in  the  skeleton  of  Nimham,  an  Oneida 
Indian,  who  was  a  great  fighter,  and  who  died  when  about  forty-five 
years  old,  in  consequence  of  severe  injuries  received  in  a  street  brawl; 
but  his  death  did  not  occur  until  four  or  five  months  after  the  receipt 
of  the  injuries. 

In  addition  to  this  fracture  of  the  right  scapula,  five  of  his  ribs 
were  broken,  and  both  legs,  all  of  which,  except  the  scapula,  had 
united  completely  by  intermediate  and  ensheathing  callus. 

The  scapula  was  broken  nearly  transversely,  the  fracture  com- 
mencing upon  the  posterior  margin  at  a  point  about  three-quarters  of 
an  inch  below  the  spine,  and  extending  across  the  body  of  the  bone 
one  inch  and  three-quarters,  in  a  direction  inclining  a  little  upwards, 
being  irregularly  denticulate  and  without  comminution.  The  frag- 
ments were  in  exact  apposition,  and,  throughout  most  of  their  extent, 
in  immediate  contact.  They  were,  however,  not  consolidated  at  any 
point,  but  upon  either  side  of  the  fissure  there  was  a  ridge  of  en- 
sheathing callus,  of  from  one  to  three  or  four  lines  in  breadth,  and  of 
half  a  line  or  less  in  thickness  along  the  broken  margin,  from  which 
point  it  subsided  gradually  to  the  level  of  the  sound  bone.  The  same 
was  observed  upon  the  inner  as  well  as  upon  the  outer  surface  of  the 
scapula.  This  callus  had  assumed  the  character  of  complete  bone,  but 
it  was  more  light  and  spongy  than  the  natural  tissue,  and  the  outer 
surface  had  not  yet  become  lamellated.  Its  blood-canals  and  bone- 
cells  opened  everywhere  upon  the  surface. 

Directly  over  the  fracture,  and  between  its  opposing  edges,  no  callus 
existed,  but  as  the  bone  had  lain  some  time  in  the  earth  before  it  was 
exhumed,  it  is  probable  that  a  less  completely  organized  intermediate 
callus  had  occupied  this  space,  and  that,  owing  to  the  less  proportion 
of  earthy  matter  which  it  contained,  it  had  become  decomposed  and 
had  been  removed. 

M.  Yoillemier  found  the  head  of  the  humerus  penetrated  by  tw^o  or 
three  fissures;^  and  M.  Campaignac  has  reported  the  case  of  a  lad  ten 

'  Des  Fract.  Incomplet.  et  cles  Fissures,  par  J.  A.  J.  Campaignac,  1829,  p.  20. 
*  Malgaigne,  op.  cit.,  p.  35. 


92  BENDING,   PAETIAL    FRACTUEES,   AND    FISSUEES. 

or  twelve  years  old,  who  was  compelled  to  submit  to  amputation  of  his 
arm  at  the  shoulder-joint,  in  consequence  of  a  severe  injury,  in  which 
the  humerus  was  found  fissured  from  the  insertion  of  the  deltoid  to 
near  the  condyles,  extending  through  the  entire  thickness  of  the  bone, 
and  the  edges  of  the  fissure  so  much  separated  toward  its  lower  ex- 
tremity as  to  admit  the  blade  of  a  knife.'  Chaussier  has  related  a  case 
in  which  a  criminal,  who  died  soon  after  having  submitted  to  the 
torture,  was  found  to  have  a  nearly  longitudinal  fissure  of  the  radius 
in  its  upper  fourth,  and  which  penetrated  half  way  through  the  thick- 
ness of  the  bone.^  Gulliver  saw  a  fissure  in  the  pelvis  of  an  infant.^ 
Malgaigne  has  seen  two  specimens  of  this  fracture  in  the  iliac  bones, 
both  of  which  belonged,  as  he  thinks,  to  adults;  in  one,  the  fissure 
was  limited  to  the  internal  table;''  and  in  the  case  of  the  lad  reported 
by  Gariel,  as  having  a  fissure  of  the  inferior  maxilla,  there  was  also 
found  a  fissure  of  the  left  ilium,  but  which  was  limited  to  the  outer 
table/ 

M.  J.  Cloquet  has  mentioned  a  case  of  fissure  of  the  shaft  of  the 
femur  passing  through  the  condyles  and  extending  upward  to  near 
the  middle  of  the  bone.  The  fissure  was  produced  by  a  bullet,  which 
had  completely  traversed  the  bone  from  behind  forward,  a  little  above 
the  condyles. °  M.  Malgaigne  has  also  represented,  in  one  of  his  plates, 
a  fissure  of  the  femur  extending  along  the  front  of  the  bone,  some- 
what irregularly,  from  a  point  a  little  below  the  trochanter  minor  to 
near  the  condyles.^  The  bone  was  presented  to  the  Museum  of  Val- 
de-Grace,  by  M.  Fleury ;  but  it  is  to  be  regretted  that  we  have  no 
farther  account  of  this  remarkable  specimen.  Certainly,  in  the  com- 
plete absence  of  any  farther  history  of  the  case,  one  might  be  justified 
in  expressing  a  doubt  whether  it  was  not  a  fissure  occasioned  by  the 
contraction  consequent  upon  exposure  and  drying  after  death. 

The  following  account  of  a  fissure  of  the  neck  of  the  femur,  of  the 
same  character  with  those  which  now  occupy  our  attention,  is  copied 
from  the  proceedings  of  the  "  Boston  Soc.  for  Med.  Improvement,"  at 
its  regular  meeting  in  September,  1856: — 

"  Partial  Fracture  of  the  Neck  of  the  Femur  in  a  man  cet.  44  years. 
Specimen  shown  by  Dr.  Jackson. — The  fracture,  which  appears  as  a 
mere  crack  in  the  bone,  commences  anteriorly  just  above,  but  very 
near  to,  the  insertion  of  the  capsular  ligament,  runs,  along  this  inser- 
tion for  about  an  inch,  and  then  extends  directly  upward  to  the  mar- 
gin of  the  head  of  the  bone.  From  this  last  point  it  crosses  the  upper 
surface  of  the  neck  almost  in  a  straight  line,  and  at  a  little  distance 
from  the  margin  of  the  head,  but  afterward  approaches  very  closely 
to  this  margin  posteriorly ;  it  then  turns  downward  and  obliquely 
forward,  and  stops  at  a  point  about  half  way  between  the  small  tro- 
chanter and  the  head  of  the  femur,  and  two-thirds  of  an  inch  or  more 
anteriorly  to  the  line  of  this  trochanter.     The  fracture  then  involves 

'  Campaignac,  Des  Fract.  Incomplet.,  &c.,  p.  24. 

'^  Med.  Legale,  p.  447  et  seq.  ^  Gazette  Med.,  1835,  p.  472. 

*  Op.  cit.,  p.  34.  5  Bulletins  de  la  Soc.  Anat.,  1835,  p.  24. 

s  These  du  Concours  de  Pathol.  Externe,  1831,  pi.  xii.,  fig.  7.  Also,  Des  Frac,  etc., 
par  Campaignac,  1829,  p.  19.  ''  Op.  cit.,  p.  37,  pi.  1,  fig.  1. 


rissuEES.  93 

about  tliree-fourths  of  the  neck  of  the  bone  ;  the  inner-anterior  portion 
only  being  spared.  There  is  considerable  motion  between  the  neck 
and  the  shaft,  and  the  fracture  could,  undoubtedly,  be  completed  with- 
out the  application  of  any  extraordinary  force.  Dr.  J.  referred  to 
other  causes  of  partial  fracture ;  but  a  fracture  of  this  sort,  as  occurring 
in  this  situation,  and  in  a  fully  adult  subject,  he  believed  had  never  before 
been  described.  There  was,  also,  in  this  case,  a  transverse  fracture  of 
the  same  femur  midway,  with  a  split  extending  upward  nearly  to  the 
neck  of  the  bone  ;  and  still  further,  a  fracture  of  the  spine.  The  patient, 
a  laboring  man,  fell  through  two  stories  of  a  building  and  down  upon 
a  hard  floor.  On  the  same  day  he  entered  the  Massachusetts  General 
Hospital,  and  on  the  18th  day  from  the  time  of  the  accident  he  died. 
The  femur  is  perfectly  healthy  in  structure,  and  no  changes  are  ob- 
servable in  the  bone  about  the  fracture.'" 

Whatever  doubts  may  have  been  thrown  upon  the  possibility  of  this 
accident,  as  applied  to  the  neck  of  the  femur,  by  the  ingenious  argu- 
ments of  Robert  Smith,  of  Dublin,^  the  question  is  now  at  least  deter- 
mined by  an  incontestable  fact.  Dr.  Smith  had  rendered  it  quite  pro- 
bable that  both  Colles  and  Adams  were  mistaken,  and  that  the  cases 
described  by  them  were  examples  of  impacted  fracture,  and  not  of 
partial  fracture;  but,  in  arguing  the  improbability  of  its  occurrence, 
from  the  infrequency  of  fractures  of  the  neck  of  the  femur  in  early 
life,  he  overlooked  the  fact  that  there  were  two  forms  of  incomplete 
fractures,  and  that  it  was  only  the  "  green  stick"  fracture  which  be- 
longed mostly  to  childhood;  "fissures"  being  found  most  often  in  the 
bones  of  adults.  Indeed,  I  think  the  example  recorded  by  Tournel 
in  the  Archives  de  Medecine^  had  already,  so  early  as  the  year  1837, 
established  the  possibility  of  a  "fissure"  in  the  neck  of  the  femur;  al- 
though by  Malgaigne  this  case  has  been  mentioned  as  an  example  of 
that  other  variety  of  partial  fractures,  which  is  almost  peculiar  to 
childhood,  and  in  which  the  bones  yield  quite  as  much  by  bending  as 
by  breaking.  But  the  man  was  eighty-five  years  old,  and,  having 
died  three  months  and  a  half  after  the  accident,  a  long  crevice  was 
found,  extending  nearly  through  the  neck  of  the  femur,  partly  within 
and  partly  without  the  capsule. 

I  have  seen,  in  Dr.  Mutter's  valuable  collection  of  bones  at  Phila- 
delphia, a  specimen  of  fissure  of  the  trochanter  major,  which,  it  is 
believed,  occasioned  the  death  of  the  patient  by  hemorrhage. 

Gulliver  says  there  is  an  example  of  a  fissure  in  a  patella  belonging 
to  the  museum  of  the  Edinburgh  College  of  Surgeons  ;  the  fissure  tra- 
versing its  articular  face  only.^ 

The  first  example  of  a  fissure  of  the  tibia  is  recorded  by  Corn.  Stal- 
part  Yander-Wiel,  in  1687;  and  indeed  this  is,  according  to  Cam- 
paignac,  the  first  exact  observation  of  this  species  of  fracture  which 
our  science  possesses,  although  its  existence  had  been  recognized  by 

'  Bost.  Med.  and  Surg.  .Totirn.,  vol.  Iv.  p.  351.  See,  also,  Amer.  Journ.  Med.  Sci. 
for  1857,  p.  306  ;  with  engraving. 

^  Treatise  on  Fractures  in  the  Vicinity  of  Joints,  etc.,  by  Robert  Wm.  Smith, 
Dublin,  1854,  p.  44  et  seq. 

*  Malgaigne,  op.  cit.,  page  35. 


94  BENDING,   PARTIAL    FRACTURES,   AND    FISSURES. 

the  most  ancient  authors.  A  servant  had  been  kicked  by  a  horse,  and 
after  a  time,  pain  continued  in  the  limb,  his  surgeon,  Dufoix,  suspected 
a  fissure  of  the  tibia,  and  having  cut  down  to  the  bone,  a  cure  was 
soon  effected.' 

In  the  Dupuytren  Museum,  at  Paris,  there  are  two  tibise  with  linear 
fractures ;  one  without  history,  and  the  other  presented  by  MM.  Mar- 
jolin  and  Rullier,  "  and  which  had  been  broken  by  a  ball."^  In  the 
example  related  by  Campaignac,  a  woman,  having  leaped  from  a 
second-story  window,  died  immediately,  and  upon  examination  she 
was  found  to  have  three  fissures  in  the  upper  portion  of  the  left  tibia, 
one  only  of  which  entered  the  articulation.^ 

The  soldier  spoken  of  by  Bdcane,  having  been  struck  upon  the 
middle  of  the  tibia,  continued  to  march  for  some  distance ;  but  serious 
complications  ensuing,  he  finally  died.  A  fissure  was  found,  after 
death,  near  the  middle  of  the  shaft  of  the  tibia." 

Leveille  relates  that  an  Austrian  soldier  had  his  leg  penetrated  by 
a  ball  at  the  battle  of  Marengo;  from  thence  he  marched  several  miles, 
and  then  was  transported  to  Pavia.  Although  the  wound  at  first 
seemed  very  simple,  graver  symptoms  soon  followed,  and  it  became 
necessary  to  amputate  the  thigh.  Dissection  showed  that  the  ball  had 
occasioned  several  oblique  and  longitudinal  fissures,  which  extended 
nearly  the  whole  length  of  the  shaft  of  the  bone.^ 

Duverney  saw  a  priest  who  had  fallen  and  bruised  the  middle  of  his 
left  leg ;  the  swelling  and  pain  consequent  upon  which  were  subdued 
after  a  few  days.  The  patient  believed  himself  cured  and  acted  ac- 
cordingly. Suddenly,  in  the  night,  he  was  seized  with  an  acute  pain 
in  the  limb  ;  and  on  cutting  down  to  the  bone,  a  bloody  serum  escaped 
from  between  it  and  the  periosteum,  and  the  bone  was  discovered  to 
be  fissured  longitudinally.  Subsequently  the  tibia  was  trephined,  but 
the  fissure  did  not  reach  the  marrow.  He  recovered  completelj^  in  less 
than  two  months. 

The  same  writer  mentions  another  case  in  which  a  soldier  received 
the  kick  of  a  horse  in  the  middle  of  his  left  leg  which  was  followed 
immediately  by  great  pain,  and  subsequently  by  much  inflammation, 
and  even  gangrene  of  the  skin.  The  wound,  however,  cicatrized 
kindly,  but  after  three  months  he  was  seized  suddenly  with  a  severe 
pain  in  the  limb;  and,  after  the  trial  of  many  remedies,  resort  was 
finally  had  to  the  knife,  when  the  tibia  was  seen  to  be  discolored,  and 
cracked  longitudinally.  On  the  following  day  the  bone  was  opened 
over  the  course  of  the  fissure  with  a  chisel  and  mallet,  and  the  patient 
was  at  once  relieved  by  the  escape  of  a  yellowish  and  very  oli'ensive 
matter.  At  the  next  dressing,  the  bone  was  opened  more  freely  by 
several  applications  of  the  trephine,  and  an  abscess  was  exposed  in 
the  centre  of  the  bone.  The  patient  finally  recovered  after  about  four 
months.^      M.  Campaignac  saw,  also,  at  the  hospital  La  Charity,  the 

■  Gampaignac,  op.  cit.,  p.  17. 

^  Malgaigne,  op.  cit.,  p.  36.  '  Campaignac,  op.  cit.,  p.  21. 

^  Abrege  des  Maladies  qui  attaquent  la  Substance  des  Os.     Toulouse,  1775,  p.  134. 

^  Malgaigne,  op.  cit.,  p.  39.  ^  Malgaigne,  op.  cit.,  p.  '6[)  et  seq. 


FISSURES.  95 

tibia  of  a  woman,  set.  38  years,  upon  which  were  found  four  fissures; 
the  report  of  which  case  is  accompanied  with  a  wood-cut  illustration.' 

Fissures  may  occur  probably  at  all  periods  of  life,  but  they  are  more 
frequently  found  in  the  bones  of  adults.  Campaignac,  however,  men- 
tions a  fissure  of  the  humerus  in  a  child  ten  or  twelve  years  old,  and 
Gulliver  has  .seen  a  fissure  in  the  pelvis  of  an  infant. 

Etiology. — They  may  be  occasioned  by  most  of  those  causes  which 
produce  fractures  in  general,  such  as  direct  or  indirect  shocks ;  but 
they  are  occasioned  much  more  often  by  direct  blows,  especially  when 
inflicted  upon  bones  imperfectly  covered  by  soft  parts,  such  as  the 
tibia.  Bullets,  having  violently  struck  or  penetrated  the  bone,  have 
frequently  occasioned  fissures. 

Their  course  may  be  parallel  with  the  axis  of  the  bone,  oblique 
or  transverse;  they  are  often  multiple;  some  merely  enter  the  outer 
laminae,  others  open  into  the  cellular  tissue,  and  others  still  divide  both 
surfaces  of  the  bone  through  and  through;  and,  according  as  they 
penetrate  more  or  less  deeply  the  bone,  their  lips  will  be  found  to  be 
more  or  less  separated.    They  frequently  extend  into  the  joint  surfaces. 

Diagnosis. — The  signs  which  indicate  the  existence  of  a  fissure  must, 
in  a  large  majority  of  cases,  be  insufficient  to  determine  fully  the 
diagnosis  during  the  life  of  the  patient.  It  is  not  probable  that  such 
fissures  could  ever  be  clearly  made  out  by  the  touch  alone,  where  the 
skin  is  not  broken,  since  the  pain,  swelling,  suppuration,  etc.,  are  only 
characteristic  of  inflammation  of  the  bone  or  of  its  coverings,  and 
might  be  equally  present  whether  a  fracture  existed  or  not.  In  those 
rare  cases  only  in  which  the  flesh  is  torn  off,  and  the  surface  of  the 
bone  is  brought  directly  under  the  observation  of  the  eye,  will  the 
diagnosis  become  certain. 

Treatment. — Fortunately,  an  error  in  judgment  in  this  matter  will 
not  materially,  if  at  all,  prejudice  the  interests  of  the  patient;  since 
whatever  may  be  the  fact  in  other  respects,  if  the  bone,  or  its  perios- 
teum, or  its  medullary  membrane,  is  inflamed,  and  rest,  with  anti- 
phlogistics,  does  not  accomplish  its  speedy  resolution,  incisions  and 
perforations  become  inevitable,  if  we  would  give  either  safety  or  relief 
to  the  sufferer.  Accordingly,  in  the  inflammation  and  suppuration 
consequent  upon  these  fractures,  we  have  seen  that  it  has  been  occa- 
sionally found  necessary  to  lay  open  the  soft  tissues  freely,  and  even 
to  trephine  the  bone  at  one  or  more  points. 

Fissures  in  Cartilage. — I  have  once  met  with  a  fissure  in  the  thyroid 
cartilage,  which  constitutes,  so  far  as  I  know,  the  only  example  upon 
record  of  a  fissure  in  cartilage.^ 

'  Campaignac,  op.  cit.,  pp.  21-22. 

2  See  Buffalo  Med.  Jouru.,  vol.  xiii.  Article  entitled  Fracture  of  the  Thyroid  Car- 
tilaa;e. 


96  FKACTURES    OF    THE    NOSE. 


CHAPTER   VIII. 

FRACTURES   OF  THE  NOSE. 

§  1.  OssA  Nasi. 

Of  twenty-two  cases  of  fracture  of  the  ossa  nasi  recorded  by  me 
only  thirteen  were  seen  by  a  surgeon  in  time  to  afford  relief.  It 
seemed  to  me  necessary,  therefore,  that  the  student  should  be  in- 
structed how  frequently  the  nature  of  this  accident  is  overlooked 
by  the  friends,  and  even  by  the  surgeon  himself,  to  the  end  that 
he  might  be  thus  admonished  of  the  necessity  of  always  instituting  in 
such  cases,  careful  and  thorough  examinations.  In  some  of  the  cases 
recorded  in  my  notes,  where  surgeons  were  called  in  time,  and  a  de- 
formity remains,  it  is  not  improbable  that  the  accident  was  not  recog- 
nized. The  rapidity  with  which  swelling  ensues  after  severe  blows 
upon  the  nose,  concealing  at  once  the  bones,  and  lifting  the  skin  even 
above  its  natural  level,  explains  these  mistakes.  The  nose,  also,  is 
remarkably  sensitive,  and  the  patient  is  often  exceedingly  reluctant 
to  submit  to  a  thorough  examination.  It  ought,  however,  not  to  be 
forgotten  that  the  omission  on  the  part  of  the  surgeon  to  do  his  duty 
will  not  always  be  excused,  even  though  the  patient  himself  has  pro- 
tested against  his  interference,  especially  where  an  organ  so  prominent, 
and  so  important  to  the  harmony  of  the  face,  is  the  subject  of  his 
neglect  or  mal-adjustment;  since  the  most  trivial  deviation  from  its 
original  form  or  position,  even  to  the  extent  of  one  or  two  lines,  be- 
comes a  serious  deformity. 

When  the  ossa  nasi  are  struck  with  considerable  force,  from  before 
and  from  above,  a  transverse  fracture  occurs  usually  within  from  three 
to  six  lines  of  their  lower  and  free  margins,  and  the  fragments  are 
simply  displaced  backwards,  or  if  the  blow  is  received  partially  upon 
one  side,  they  are  displaced  more  or  less  laterally.  This  is  what  will 
happen  in  a  great  majority  of  cases,  as  I  have  proven  by  examinations 
of  the  noses  of  those  persons  who  have  been  the  subjects  of  this  acci- 
dent, both  before  and  after  death,  and  by  repeated  experiments  upon 
the  recent  subject. 

These  fragments  are  generally  loose  and  easily  pressed  back  into 
place  by  the  use  of  a  proper  instrument.  A  silver  female  catheter, 
which  we  have  seen  recommended  by  surgeons,  may  answer  well 
enough  in  a  few  instances,  but  it  will  more  often  fail.  The  diameter 
of  the  meatus  at  the  point  where  the  instrument  must  touch  in  order 
to  make  effective  pressure  upon  the  ossa  nasi,  is  on  the  average  not 
more  than  two  lines,  and  when  the  membrane  which  lines  it  is  injured, 
it  becomes  quickly  swollen,  and  reduces  the  breadth  of  the  channel  to  a 


OSSA    NASI.  97 

line  or  less.  Under  these  circumstances,  any  instrument  of  the  size 
of  a  female  catheter  could  only  be  made  to  reach  and  press  against 
the  nasal  process  of  the  superior  maxilla,  which  is  too  firm  and  un- 
yielding to  allow  it  to  pass  without  the  employment  of  unwarrantable 
force.  In  this  way  it  happens  that  the  operator  is  occasionally  sur- 
prised to  find  how  much  resistance  is  opposed  to  his  efforts  to  lift  the 
bones,  and  after  repeated  unsuccessful  attempts  the  case  is  not  unfre- 
quently  given  over.  If,  however,  he  had  used  a  smaller  instrument, 
he  would  have  found  almost  no  resistance  whatever.  A  straight  steel 
director,  or  sound,  or  sometimes  even  a  much  smaller  instrument,  if 
possessing  sufficient  firmness,  is  more  suitable  than  the  catheter.  For 
the  same  reason,  also,  one  ought  never  to  wrap  the  end  of  the  instru- 
ment with  a  piece  of  cotton  cloth  as  some  have,  I  suspect,  without 
much  consideration,  recommended. 

What  I  have  said  of  the  facility  with  which  these  bones  may  be 
replaced,  when  a  proper  instrument  is  employed,  is  true  only  when 
the  treatment  is  adopted  immediately,  or  at  most  within  a  few  days 
after  the  accident. 

Boyer,  Malgaigne,  and  others  have  noticed  the  fact  that  these  frac- 
tures are  repaired  with  great  rapidity.  Hippocrates  thought  the 
union  was  generally  complete  in  six  days ;  and  in  a  case  which  has 
come  under  my  own  observation,  the  fragments  were  quite  firmly 
united  on  the  seventh  day. 

A  lad  aged  eleven  years  had  the  right  nasal  bone  broken  through 
its  lower  third,  and  displaced  to  the  right  side.  Seven  days  after  the 
accident  he  was  brought  to  me,  I  introduced  a  strong  steel  instrument 
into  the  right  nostril,  and  pressed  upward  and  to  the  left,  while  with 
my  thumb  I  pressed  forcibly  upon  the  right  side  of  the  nose.  My 
object  was  to  lift  the  bone,  and  carry  it  a  little  over  to  the  left  side. 
During  the  effort,  the  bones  were  felt  to  crack  and  give  way  slightly, 
but  not  sufficiently.  I  then  gave  him  chloroform,  as  the  manipulation 
had  proved  very  painful,  and  again  pressed  in  the  same  manner  with 
great  force,  until  the  restoration  seemed  complete. 

JSTor  has  Malgaigne,  whose  observations  are  always  very  accurate, 
overlooked  the  fact,  also,  that  their  repair  is  effected  without  the  in- 
terposition of  provisional  callus,  but  as  it  were  ''■  par  premiere  intention.'''' 
My  own  observation  confirms  this  statement.  Among  all  the  speci- 
mens which  I  have  seen  in  the  various  college  and  private  collections 
illustrating  fractures  of  the  ossa  nasi,  and  amounting  in  all  to  over 
forty,  in  no  instance  has  there  been  detected,  after  a  careful  examina- 
tion, the  slightest  trace  of  provisional  callus. 

I  am  not  certain  that  it  will  always  be  found  so  easy  to  retain  these 
loose  fragments  in  place,  as  it  is  to  replace  them.  The  very  swelling 
which  takes  place  so  promptly  under  the  skin  tends  to  depress  the 
fragments,  unsupported  as  they  are  by  any  counter  force ;  a  tendency 
which,  possibly,  is  in  some  instances  increased  by  attempts  on  the 
part  of  the  patient  to  clear  his  nostrils  by  snuffing  and  hawking.  I 
have,  in  one  instance,  noticed  very  plainly  a  motion  in  the  fragments 
when  such  efforts  were  made.  How  we  are  to  remedy  this  I  am  not 
prepared  to  say.  None  of  the  plans  which  I  have  seen  suggested 
7 


98  FEACTUEES    OF    THE    NOSE. 

possess,  in  my  estimation,  very  much  practical  value.  Few  patients 
will  consent  to  the  introduction  of  pledgets  of  lint,  or  of  stuffed  bags, 
or,  indeed,  of  anything  else,  sufficiently  far  up  into  the  nostril  to 
answer  any  useful  purpose.  The  membrane  is  too  sensitive  and  too 
intolerant  of  irritants  to  enable  us  to  have  recourse  generally  to  such 
methods.  Then,  too,  it  would  require  on  the  part  of  the  surgeon 
more  than  ordinary  tact  to  accomplish  so  nice  and  delicate  an  adjust- 
ment of  the  supports  from  below  as  these  cases  demand,  where  the 
slightest  excess  of  pressure  or  the  least  fault  in  the  position  of  the 
compress  must  defeat  the  purpose  of  the  operator. 

Yet,  if  one  were  disposed  to  make  the  attempt  in  certain  cases 
where  the  comminution  was  very  great,  or  where  for  any  other  reason 
the  fragments  would  not  remain  in  place,  I  think  there  could  be  no 
better  plan  than  to  push  up  in  succession  a  number  of  small  pledgets 
of  patent  lint,  smeared  with  simple  cerate,  to  each  one  of  which  there 
has  been  attached  a  separate  string,  so  arranged  as  that  their  relative 
position  may  be  recognized,  and  that  they  may  at  a  suitable  time  be 
removed  in  the  order  of  their  introduction. 

The  employment  of  canulas,  as  recommended  by  Boyer,  B,  Bell, 
and  others,  allows  of  the  nostrils  being  stuffed,  without  interfering 
materially  with  the  breathing ;  a  provision,  however,  which  is  quite 
unnecessary  with  a  majority  of  persons,  so  long  as  there  exists  no 
impediment  to  the  free  admission  of  air  through  the  fauces. 

With  nicely  adjusted  compresses  made  of  soft  cotton  or  lint,  and 
secured  upon  the  outside  of  the  nose  with  delicate  strips  of  adhesive 
plaster  or  rollers,  we  shall  be  better  able  to  prevent  the  fragments 
from  becoming  displaced  outwards,  than  by  moulds  of  wax,  of  lead, 
or  of  gutta  percha,  under  which  it  is  impossible  to  see  from  hour  to 
hour  what  is  transpiring. 

The  complicated  apparatus  devised  by  Dubois  and  recommended 
by  Malgaigne,  to  lift  the  bones  and  retain  them  in  place,  seems  to  me 
indeed  very  ingenious,  but  destitute  of  a  single  practical  advantage. 

A  more  considerable  force  than  that  which  I  have  first  supposed, 
will  break,  generally,  the  ossa  nasi  transversely  and  a  little  above 
their  middle,  while,  at  the  same  time,  the  nasal  processes  of  the 
superior  maxillary  bones  may  suffer  slightly. 

With  neither  of  these  accidents  is  the  cribriform  plate  of  the 
ethmoid  likely  to  be  broken  or  disturbed.  Indeed,  in  numerous  ex- 
periments made  upon  the  recent  subject,  and  in  which  the  force  of 
the  blow  was  directed  backwards  and  upwards,  breaking  and  com- 
minuting the  nasal  bones  above  and  below  their  middle,  with,  also, 
the  nasal  processes  of  the  superior  maxillary  bones,  and  the  septum 
nasi,  the  cribriform  plate  of  the  ethmoid  was,  without  an  exception, 
uninjured.  The  exceeding  tenuity  and  flexibility  of  the  septum  nasi 
at  certain  points,  prevents  effectually  the  concussion  from  being  com- 
municated through  it  to  the  base  of  the  brain.  If,  therefore,  after 
these  accidents,  cerebral  symptoms  are  occasionally  present,  as  I  have 
myself  twice  seen,'  they  must  be  due  rather  to  the  concussive  effects 

'  Report  on  Deformities  after  Fractures,  Cases  16  and  18. 


0S3A    NASI.  99 

of  the  blow  upon  the  very  summit  of  the  nasal  bones,  where  the  v  re?t 
immediately  upon  the  nasal  spine  of  the  os  frontis,  or  to  some  direct 
impression  upon  the  skull  itself. 

The  amount  of  force  requisite  to  break  in  the  nasal  bones,  at  their 
upper  third,  is  very  great ;  no  less,  indeed,  than  is  requisite  to  fracture 
the  03  frontis.  If  they  do  finally  yield  at  this  point,  then  no  doubt 
the  base  of  the  skull  must  yield  also.  Nor  do  I  think  patients  could 
often  be  expected  to  recover  from  an  accident  so  severe.  To  this  class 
of  fractures  belongs  the  specimen  contained  in  my  museum,  in  which 
not  only  both  of  the  nasal  bones  are  sent  in — the  nasal  spine  being 
broken  at  its  base — but  also  the  os  frontis  is  depressed,  the  nasal  pro- 
cesses of  the  upper  maxillary  bones  are  broken  and  greatly  displaced, 
and  the  anterior  half  of  the  cribriform  plate  of  the  ethmoid  is  forced  up 
into  the  base  of  the  brain.  If  it  is  meant  that  in  these  cases  the  patient 
is  in  danger  from  injury  done  to  the  base  of  the  skull,  through  the 
fracture  and  depression  of  the  ossa  nasi,  we  can  appreciate  the  value 
of  the  opinion ;  but  we  do  not  understand  how  this  danger  can  exist 
when  the  nasal  spine  of  the  os  frontis  is  not  broken,  and  the  upper 
ends  of  the  nasal  bones  are  not  displaced  backwards.  But,  admitting 
that  it  were  possible  in  this  way  to  force  up  the  base  of  the  skull,  it 
does  not  seem  to  me  that  we  ought  to  attach  any  value  to  the  advice 
occasionally  given,  to  attempt  to  restore  the  broken  ethmoid  by  seiz- 
ing upon  the  septum  and  pulling  downwards.  A  force  sufficient  to 
break  the  base  of  the  skull,  never  fails  to  comminute  and  detach  almost 
completely  the  septum  nasi.  ^Ye  are  to  proceed  in  such  a  case  as  we 
would  in  a  case  of  broken  skull.  We  must  lay  open  the  skin  freely, 
and  with  appropriate  instruments  seek  to  elevate  and  remove,  if  neces- 
sary, the  fragments.  Indeed,  after  such  accidents,  we  shall  generally 
see  plainly  enough  that  death  is  inevitable,  and  that  our  services  will 
be  of  no  value. 

Occasionally,  I  have  observed,  the  bones  are  neither  broken  at  their 
lower  ends  nor  through  their  central  diameters,  but  only  at  their 
lateral,  serrated,  or  imbricated  margins.  This  is  rather  a  displace- 
ment, or  dislocation,  than  a  fracture.  It  is  more  likely  to  happen,  I 
think,  in  childhood  than  in  middle  or  old  age,  as  in  the  following  ex- 
ample : — 

Thomas  Kelley,  aged  four  years,  was  kicked  by  a  horse.  Two  hours 
afterwards,  when  he  was  first  seen  by  a  surgeon,  the  nose  and  face 
were  much  swollen,  and  the  fracture  was  overlooked. 

One  year  after  the  accident,  I  found  both  nasal  bones  depressed 
through  nearly  their  whole  length,  and  especially  in  their  lower  halves. 
The  right  nasal  process  was  also  much  depressed,  and  the  right  nostril 
obstructed.     The  lachrymal  canals  upon  this  side  were  closed. 

Sometimes  the  lower  ends  of  the  nasal  bones  are  bent  backwards. 
or  laterally,  constituting  a  partial  fracture. 

A  lad,  aged  ten  years,  was  hit  by  one  of  his  mates,  accidentally,  with 
his  elbow,  upon  the  left  side  of  his  nose.  I  was  immediately  called, 
and  found  the  lower  end  of  the  left  os  nasi  displaced  laterally  and 
backwards,  so  that  it  rested  under  the  lower  end  of  the  right  os  nasi. 
There  did  not  appear  to  be  any  fracture  beyond  that  which  was  inevi- 


100  FEACTUEES    OF   THE    NOSE. 

table  by  the  mere  separation  of  its  serrated  margins  from  tbe  bone 
adjoining.  The  angle  formed  by  the  bone  at  the  point  where  the 
bending  had  occurred,  was  smooth  and  rounded,  and  not  abrupt  as  in 
a  complete  fracture. 

With  a  steel  instrument,  introduced  into  the  left  nostril,  I  attempted 
to  lift  the  bone  to  its  place.  The  membrane  was  very  sensitive,  and 
the  patient  very  restless  under  my  repeated  efforts.  I  pressed  up- 
wards with  considerable  force,  and  succeeded  at  length  in  bringing  the 
bone  nearly  into  position. 

If  there  is  more  complete  displacement,  the  upper  ends  are  not 
usually  forced  backwards,  but  rather  a  very  little  forwards,  from  their 
articulations  with  the  os  frontis,  and  the  bones  then  swing,  as  it  were, 
upon  the  lower  ends  of  the  nasal  spine,  as  upon  a  pivot.  In  this  con- 
dition, they  are  very  firmly  locked,  and  it  requires  considerable  force, 
applied  under  their  lower  extremities,  to  restore  them  to  place. 

Such  seemed  to  be  the  position  of  the  bones  in  the  case  of  the  lad 
Kelley,  already  mentioned,  and  also  in  a  German,  whose  nose  was 
flattened  by  a  severe  blow  when  he  was  eleven  years  old,  whom  I  saw, 
thirteen  years  after  the  accident,  in  the  Buffalo  Hospital.  In  this  last 
example  the  bones  were  very  much  displaced  backwards. 

In  children,  also,  the  nasal  bones  may  be  spread  and  flattened,  the 
lateral  margins  not  being  depressed  or  displaced,  but  only  the  mesial 
line  or  arch  forced  back,  so  as  to  press  aside  the  processes  of  the  supe- 
rior maxilla;  which  deformity  may  become  permanent. 

A  block  of  wood  fell  upon  a  child  three  weeks  old,  as  she  was  lying 
in  the  cradle.  The  nature  of  the  injury  was  not  understood  by  the 
parents,  and  no  surgeon  was  called.  The  ossa  nasi  are  now,  twelve 
years  after  the  accident,  much  wider  than  is  natural,  and  depressed ; 
the  nasal  processes  of  the  superior  maxilla  appearing  to  have  been 
spread  asunder. 

Jacob  Kibbs,  a  German,  aged  seven  years,  fell  from  a  height  of  forty 
feet,  striking  on  his  face.  His  parents  did  not  suspect  the  injury,  and 
no  surgeon  was  called.  Twenty-four  years  after  this,  I  found  the  nose 
almost  flat.  The  nasal  bones  appeared  unusually  wide,  and  were 
sunken  between  the  processes  of  the  upper  maxillary  bones,  which 
latter  might  be  recognized  by  two  parallel  ridges  on  each  side,  slightly 
rising  above  the  level  of  the  ossa  nasi. 

Benjamin  Bell  and  others  have  spoken  of  tedious  ulcers,  polypi, 
necrosis,  fistula  lachrymalis,  abscesses,  impeded  respiration,  and  im- 
pairment of  the  sense  of  smell  and  of  speech,  as  circumstances  apt  to 
result  from  these  injuries,  and  it  is  certain  that  such  consequences  have 
occasionally  followed ;  but  they  must  sometimes  be  regarded  as  acci- 
dents due  to  the  state  of  the  general  system,  and  as  having  no  connec- 
tion with  the  fracture,  except  as  this  injury  served  to  awaken  certain 
vicious  tendencies. 

Two  years  ago,  a  gentleman,  then  twenty-five  years  old,  was  struck 
accidentally  upon  the  right  side  of  his  nose  by  a  board,  and  the  ossa 
nasi  were  displaced  to  the  left.  A  surgeon  made  an  attempt  to  reduce 
them,  but  did  not  succeed,  and  they  have  remained  displaced  ever 
since. 


FRACTUEES   AND    DISPLACEMENTS    OF    SEPTUM    NAEIUII.      101 

The  nose  for  a  time  was  much  swollen.  A  few  months  after  the 
accident,  a  purulent  discharge  commenced  from  the  right  nostril,  and 
at  length  an  abscess  formed  in  the  right  cheek.  The  abscess  is  now 
healed,  but  the  nose  continues  to  discharge  pus,  and  occasionally  it 
bleeds  freely.  There  is  a  perforation  of  the  septum,  of  the  size  of  a 
three-cent  piece,  which  is  continuing  to  enlarge. 

N^o  hereditary  maladies  exist  in  the  family,  except  that,  on  his  father's 
side,  it  has  been  generally  observed  that  Avounds  do  not  heal  kindly. 
The  same  is  the  fact  with  him.  When  a  child,  he  was  also  very  sub- 
ject to  epistaxis;  at  sixteen,  a  pulmonary  difficulty  began,  and  he  had 
more  or  less  cough,  with  heemoptysis,  for  two  years.  Since  then,  his 
health  has  been  good.  He  is  a  lawyer  by  profession,  but  of  late  he 
has  lived  in  the  country,  upon  a  farm,  and  has  accustomed  himself  to 
much  out-door  exercise. 

As  to  the  prognosis  in  these  fractures,  I  can  only  say  that  either 
owing  to  the  ignorance  and  carelessness  of  the  patients  themselves, 
who  neglect  to  call  a  surgeon  in  time,  or  to  the  difficulty  of  diagnosis, 
or  to  the  greater  difficulty  in  maintaining  an  adjustment  of  the  frag- 
ments, it  has  hitherto  happened  that,  after  a  fracture  of  the  ossa  nasi, 
more  or  less  deformity  has  usually  remained.  I  have  never  seen  but 
four  which  could  be  said  to  be  perfectly  restored. 


§  2.  Fractures  and  Displacements  of  the  Septum  Narium. 

Fractures  or  displacements  of  the  septum  narium  must  occur  to 
some  extent  in  all  fractures  of  the  ossa  nasi  accompanied  with  depres- 
sion ;  but  they  are  also  occasionally  met  with  as  the  results  of  a  blow 
upon  the  nose,  which  has  been  insufficient  to  break  the  bones,  and  in 
which  only  the  cartilaginous  portion  of  the  nose  has  been  bent  inward 
upon  the  septum. 

Of  these  simple,  uncomplicated  accidents,  I  have  seen  seven ;  in 
three  of  which  no  surgeon  was  employed,  or  surgical  treatment  of  any 
kind  adopted,  and  it  is  quite  probable  that  only  in  a  small  proportion 
of  all  the  cases  was  the  nature  of  the  accident  recognized.  Such,  at 
least,  has  been  generally  the  statement  of  the  patients  themselves. 
The  same  causes  will  explain  this  which  have  been  invoked  to  explain 
similar  oversights  in  cases  of  broken  ossa  nasi.  To  which  we  may 
add,  as  an  additional  reason  why  it  may  be  overlooked,  the  frequency 
of  lateral  distortions  or  deviations  in  the  natural  development  of  this 
septum. 

The  cartilaginous  portion  of  the  septum  is  that  which  is  most  fre- 
quently displaced  by  violence,  and  then  it  is  usually  at  the  point  of 
its  articulation  with  the  bony  septum.  Next,  in  point  of  frequency, 
the  perpendicular  nasal  plate  is  broken,  and  especially  where  it  ap- 
proaches the  vomer.  We  omit  in  this  enumeration,  of  course,  those 
cases  where  the  nasal  bones  themselves  are  broken  down,  in  most  or 
all  of  which,  as  we  have  already  said,  the  perpendicular  plate  is  more 
or  less  fractured  and  displaced.  We  cannot  say  how  often  the  vomer 
is  broken,  since  it  is  beyond  our  observation,  except  in  autopsies.     It 


102  FRACTUEES    OF    THE    NOSE. 

is  probable,  however,  that  the  force  of  the  coucussion  rarelj  reaches 
it,  the  cartilage  or  the  perpcDdicular  plate  giving  way  first  and  easily. 

Where  the  deviation  is  only  lateral,  the  results  are  less  serious,  yet 
sufficiently  so  in  a  few  instances  to  demand  our  attention.  Lateral 
obliquity  of  the  lower  portion  of  the  nose  follows  generally,  but  not 
uniformly,  a  lateral  displacement  of  the  cartilage,  and  when  it  does 
exist,  it  is  not  always  proportioned  to  the  amount  of  displacement  ex- 
isting in  the  septum,  so  that  the  septum  is  then  made  to  project  ob- 
liquely across  the  nasal  passage,  causing  often  a  serious  obstruction 
and  permanent  inconvenience.  In  one  instance,  also,  I  have  known 
it  to  occasion  a  chronic  catarrh. 

A  lad,  set.  15,  was  struck  violently  on  the  nose,  which  became  im- 
mediately much  swollen,  but  no  surgeon  was  called.  Eight  years 
after,  I  found  the  septum  displaced  laterally,  and  to  the  left  side,  pro- 
ducing also  a  slight  lateral  inclination  of  the  end  of  the  nose.  He 
was  unable  to  breathe  freely  through  the  left  nostril,  and  from  the 
same  side  a  catarrhal  discharge  had  continued  from  the  time  of  the 
accident. 

The  following  example,  in  which  the  accident  has  been  followed  by 
a  morbid  condition  of  the  cutaneous  glands,  is  of  more  difficult  ex- 
planation : — 

A  young  man,  set.  23,  called  upon  me,  supposing  that  he  had  a 
polypus  nasi.  I  found  that  in  consequence  of  a  fall  upon  the  ice,  seven 
years  before,  the  septum  narium  had  been  displaced  to  the  right  so  as 
to  almost  completely  close  this  nostril.  In  very  cold  weather,  when 
the  vessels  of  the  membrane  are  contracted,  the  passage  is  more  free. 
The  left  nostril  is  proportionably  wide. 

During  the  last  four  or  five  years,  the  right  side  of  his  face  has  been 
subject  to  profuse  perspiration.  It  is  almost  constant  in  summer, 
and  only  occasional  in  winter.  The  line  of  division  between  the  per- 
spiring and  non-perspiring  portions  of  the  face  passes  perpendicularly 
from  the  top  of  the  centre  of  the  forehead,  along  the  ridge  of  the  nose, 
and  down  to  the  centre  of  the  chin.  The  phenomenon  is  due,  perhaps, 
to  an  increased  vascularity  in  the  right  side  of  the  face ;  possibly  to 
some  peculiarity  in  the  condition  of  the  nervous  trunks,  occasioned  by 
the  nasal  obstruction. 

A  depression  of  the  cartilage  forming  a  portion  of  the  ridge  of  the 
nose  is  necessarily  accompanied  with  a  corresponding  degree  of  late- 
ral displacement,  with  or  without  fracture,  of  its  perpendicular  portion, 
and  produces,  therefore,  not  only  great  deformity,  sometimes  a  com- 
plete flattening  of  the  end  of  the  nose,  but,  also,  in  some  instances, 
complete  obstruction  of  the  nostrils. 

We  conclude,  from  all  that  we  have  seen,  that  fractures  and  displace- 
ments of  the  septum  narium  are  generally  followed  by  permanent 
deformity,  and  occasionally  with  still  more  serious  results.  We  sug- 
gest, therefore,  a  more  careful  examination  in  recent  injuries,  with  a 
view  to  the  ascertainment  of  its  lesions,  and  it  would  be  well,  cer- 
tainly, if  we  could  devise  some  reliable  mode  of  treatment. 

It  is  doubtful  whether  a  partition  so  thin  and  unsupported  can  ever 
be  well  adjusted  and  supported  by  artificial  means.     We  possess,  how- 


FRACTUEES    AND    DISPLACEMENTS    OF    SEPTUM    NARIUM.      103 

ever,  one  advantage  in  the  treatment  of  this  accident  which  we  do  not 
in  the  treatment  of  broken  ossa  nasi,  viz  :  facility  of  observation  and 
of  approach,  and  if  we  can  do  little  with  plugs  and  supports  in  the 
one  case,  we  may  possibly  do  more  in  the  other.  Nothing  seems 
more  rational,  then,  than  to  plug  carefully  and  equally  each  nostril, 
with  pledgets  of  lint,  while  we  cover  the  outside  of  the  nose  completely 
with  a  nicely  moulded  gutta  percha  splint  or  case,  which  ought  to  be 
made  to  press  snugly  upon  the  sides,  and  permitting  these  to  remain 
for  several  weeks,  or  until  the  cure  is  completed.  The  papier  macM 
of  Dzondi,  employed  by  him  in  cases  of  broken  ossa  nasi,  would  be 
equally  applicable  here ;  but  the  gutta  percha,  as  being  more  plastic, 
and  hardening  more  quickly,  ought  to  be  preferred. 

Attempts  to  remedy  the  deformities  of  the  nose  at  a  later  period, 
belong  to  the  department  of  anaplastic  surgery,  and  the  modes  of 
procedure  must  be  varied  according  to  the  circumstances  of  the  case. 

The  following  example  will  serve  as  an  illustration  of  what  may 
sometimes  be  accomplished  in  these  cases : — 

A  young  man  fell  from  a  two-story  window,  striking  upon  his  face. 
A  surgeon  was  called,  but  he  did  not  discover  the  nature  of  the  injury 
to  the  nose. 

One  year  after  the  accident  he  called  upon  me  for  relief.  The  car- 
tilaginous portion  of  the  septum  was  broken  just  at  the  ends  of  the 
nasal  bones,  and  forced  backwards  about  three  lines,  producing  a  strik- 
ing depression  at  this  point  of  the  ridge  of  the  nose,  while  at  the  same 
time  the  end  of  the  nose  was  thrown  up.  The  deformity  was  very 
unseemly,  and  annoying  both  to  himself  and  to  his  friends,  who  at  first 
could  scarcely  recognize  him. 

I  introduced  a  narrow,  sharp-pointed  bistoury  through  the  skin  of 
the  nose  on  the  right  side,  and  resting  its  edge  upon  the  ridge  at  the 
junction  of  the  cartilage  with  the  ossa  nasi,  I  cut  the  cartilaginous  sep- 
tum directly  backwards  about  three  lines,  and  then  making  a  gradual 
curve  with  my  knife,  I  cut  downwards  about  eight  lines  towards  the 
end  of  the  nose.  The  intercepted  portion  of  cartilage  could  now  be 
easily  lifted  with  a  probe,  and  the  line  of  the  ridge  of  the  nose  com- 
pletely restored.  It  was  at  once  apparent,  also,  that  lifting  the  carti- 
lage would  depress  the  tip  of  the  nose  and  restore  its  symmetry. 

To  retain  the  cartilage  in  place,  I  constructed  a  gutta  percha  splint, 
of  the  length  and  shape  of  the  nose,  but  so  formed  along  its  middle  as 
that  it  would  not  press  upon  the  cartilage  which  I  had  lifted,  resting 
well  upon  the  ossa  nasi,  but  not  touching  the  ridge  from  the  lower 
ends  of  these  bones  to  the  tip  of  the  nose,  at  which  latter  point  it  again 
received  support.  I  now  passed  a  needle,  armed  with  a  stout  ligature, 
through  the  upper  end  of  the  uplifted  cartilage,  transfixing,  of  course, 
the  skin  on  both  sides  of  the  nose,  and  this  I  tied  firmly  over  the  splint. 
This  accomplished  the  important  object  of  pressing  backwards  and 
downwards  the  tip  of  the  nose,  and  thus  tilting  up  the  upper  part  of 
the  ridge  and  septum,  and  of  more  eflectually  securing  the  cartilage 
in  place  by  lifting  it  directly  with  the  ligature.  On  the  second  day 
the  ligature  was  removed,  but  the  splint  was  continued  two  weeks. 


lOi  FEACTUEES    OF    THE    MALAE    BOISTE. 

during  most  of  whicli  time  a  band  was  kept  drawn  across  the  lower 
end  of  the  splint,  and  tied  behind  the  neck. 

To  prevent  the  cartilage  from  falling  back  when  final  cicatrization 
occurred,  I  pressed  the  sides  of  the  splint  firmly  towards  each  other, 
just  below  the  incision,  so  as  to  force  as  much  as  possible  the  walls  of 
the  nares  into  the  fissure  in  the  septum,  made  by  lifting  it  up. 

The  result  is  a  complete  and  perfect  restoration  of  the  nose  to  its 
original  form. 


CHAPTER    rX. 

FEACTUEES   OF  THE  MALAE  BONE. 

I  HAVE  been  unable  to  find  any  records  of  a  simple  fracture  of  the 
malar  bone,  that  is  to  say,  of  a  fracture  unconnected  with  a  fracture  of 
other  bones  of  the  face.  It  is  probable,  however,  that  it  sometimes 
occurs,  but  that  not  being  accompanied  with  much  displacement,  it  is 
overlooked.  I  have  myself  seen  a  fracture  of  the  upper  margin,  or  of 
that  portion  which  constitutes  a  part  of  the  orbital  border,  in  two  or 
three' instances,  while  I  was  unable  to  detect  any  other  fracture  among 
the  bones  of  the  face ;  but  it  is  by  no  means  certain  that  other  fractures 
did  not  exist,  perhaps  in  some  of  the  .bones  which  form  the  socket,  or 
in  the  superior  maxilla,  as  mere  fissures,  or  as  fractures  with  only 
slight  displacement.  The  prominence  of  the  malar  bone  and  especially 
the  sharpness  of  its  orbital  margin  would  enable  the  surgeon  to  de- 
tect easily  the  smallest  displacement,  or  even  a  fissure,  while  a  much 
more  extensive  displacement  elsewhere  would  escape  detection. 

The  following  observations  will  illustrate  these  remarks : — 

Observation  First. — With  a  heavy  steel  hammer  I  struck  the  left 
malar  bone  of  a  naked  skull,  breaking  the  orbital  margin  near  its 
middle,  the  line  of  fracture  extending  backward  through  the  whole 
length  of  the  orbital  plate,  and  the  outer  half  of  the  plate  being  pressed 
about  two  lines  into  the  orbital  cavity.  There  was  no  other  fracture 
of  the  malar  bone. 

The  nasal  process  of  the  superior  maxilla  was  broken  near  its  base, 
and  the  whole  upper  portion  of  this  bone  was  thrown  inward  toward 
the  nasal  passages  in  such  a  manner  as  nearly  to  close  them ;  while 
its  lower  margin  was  thrown  out,  separating  the  two  upper  maxillary 
bones  from  each  other  along  the  whole  line  of  the  inter-maxillary 
suture.  This  separation  was  about  two  lines  in  front  and  less  toward 
the  palatal  bones. 

The  ethmoid  was  fissured  through  the  whole  length  of  its  os  planum, 
from  before  backward. 

It  is  very  easy  to  understand  how  a  blow  upon  the  malar  bone, 


FRACTURES  OF  THE  MALAR  BONE.  105 

coming  a  little  from  one  side,  should  produce  this  form  of  displace- 
ment of  the  superior  maxilla. 

The  two  upper  maxillary  bones  form,  as  they  are  placed  opposite  to 
each  other,  an  irregular  arch,  one  end  of  whicli  rests  upon  its  fellow, 
at  the  intermaxillary  suture,  and  the  other  end  rests  upon  the  nasal 
and  frontal  bones;  while  over  the  centre  of  the  arch  is  situated  the 
malar  bone.  The  force  of  a  side  blow  upon  the  malar  bone  will  ex- 
pend itself  therefore  chiefly  upon  the  base  of  the  maxillary  apophysis, 
as  being  in  the  line  of  the  direction  of  the  force.  The  force  continuing 
to  act,  after  the  apophysis  is  broken,  the  portion  of  the  superior  max- 
illa above  the  floor  of  the  nares  will  fall  inward  toward  the  septum, 
while  the  portion  below  will  tilt  outward  and  open  the  inter-maxillary 
suture  along  the  roof  of  the  mouth.  This  suture  will  also  open  more 
widely  in  front  than  behind,  owing  to  the  greater  depth  of  the  suture 
in  front. 

One  might  suppose  that  it  would  be  a  very  easy  matter  to  restore 
these  bones  to  place  upon  the  naked  skull,  after  such  an  accident. 
Certainly  it  would  be  very  desirable  to  do  so,  were  this  accident  to 
occur  to  any  patient,  since  the  malar  bone  is  slightly  depressed,  the 
nostril  upon  this  side  is  nearly  closed,  and  the  line  of  the  teeth  is  dis- 
turbed, and  it  is  possible  also  that  an  opening  might  be  established 
between  the  nose  and  mouth  immediately  back  of  the  incisors.  In 
fact,  however,  I  found  the  restoration  impossible.  It  could  not  be  ac- 
complished by  an  instrument  within  the  nose  pressing  outward,  nor 
by  pressing  inward  upon  the  teeth  and  alveoli ;  not  certainly  without 
very  great  and  unwarrantable  force.  The  difficulty  consisted  simply 
in  the  antagonisms  of  the  serrated  margins  of  the  intermaxillary 
suture,  which  projecting  one  or  two  lines  on  each,  side,  could  not  be 
made  to  interlock  again,  but  were  firmly  braced  against  each  other. 

A  repetition  of  the  blow  broke  the  malar  bone  completely  in  two, 
disarticulating  it  also  at  its  zygomatic  suture. 

The  superior  maxilla  was  now  separated  wholly  from  the  other  bones 
of  the  face  and  skull,  carrying  the  palate  bone  with  it  entire.  The 
body  and  sinus  of  the  upper  maxilla  still,  however,  remained  unbroken. 

Observation  Second. — A  blow  inflicted  with  the  hammer,  square  upon 
the  malar  bone,  broke  the  malar  bone  on  its  orbital  margin  in  the 
same  manner  as  in  Observation  First.  There  was  also  a  fissure  on  the 
upper  and  outer  margin  of  the  bone.  There  was  no  other  fracture  of 
the  malar  bone. 

The  zygoma  was  broken  transversely  near  its  middle,  through  that 
portion  which  belongs  to  the  temporal  bone. 

The  superior  maxilla  was  broken  through  the  antrum,  a  little  below 
the  base  of  the  malar  eminence,  and  the  malar  bone  was  forced  into 
the  antrum  several  lines.     The  dental  arcade  was  not  broken. 

The  ethmoid  bone  was  fissured  antero-posteriorly  through  its  orbital 
plate. 

In  this  example  the  walls  of  the  antrum  having  at  once  given  way, 
the  force  of  the  blow  did  not  reach  the  nasal  apophysis.  It  was  found 
very  easy  to  lift  the  malar  bone  to  its  place,  with  an  instrument  in- 
troduced through  the  broken  walls  of  the  antrum. 


106  FRACTURES  OF  THE  MALAR  BONE. 

Observation  Third. — The  hammer  falling  upon  the  malar  bone  de- 
pressed it  slightly,  but  did  not  break  it. 

The  superior  maxilla  was  found  broken  through  the  walls  of  the 
antrum  a  little  below  the  malar  apophysis.     No  other  fracture. 

The  second  blow  broke  the  malar  bone  through  its  centre,  breaking 
also  the  zygoma  near  its  centre. 

The  third  blow  broke  the  nasal  apophysis  of  the  superior  maxilla 
near  its  base,  comminuting  the  antrum ;  into  which  the  malar  bone 
was  forcibly  driven.  At  the  same  time  the  orbital  plate  of  the  malar 
bone  was  thrown  up  into  the  socket.     The  ethmoid  was  also  broken. 

Observation  Fourth. — The  first  blow  did  not  fracture  the  malar  bone, 
but  broke  the  walls  of  the  antrum,  and  at  the  same  moment  produced 
a  fissure  extending  vertically  through  the  dental  arcade  between  the 
first  and  second  molars,  into  the  mouth. 

The  second  blow  broke  the  malar  bone  through  its  centre  irregularly, 
and  also  the  zygoma  transversely,  near  the  centre  of  its  arch.  The 
nasal  process  of  the  superior  maxilla  was  broken  at  two  points,  one  of 
the  lines  of  fracture  extending  into  the  orbital  socket. 

The  skull  was  also  found  broken  at  its  base  through  the  lesser  wings 
of  Ingrassias;  the  force  of  the  blow  having  been  conveyed,  appa- 
rently, along  the  orbital  plate  of  the  superior  maxilla  and  os  planum. 

This  is  the  only  example  in  which  the  fracture  extended  through 
the  dental  arcade,  and  it  was  the  result  of  the  first  blow.  The  fracture 
of  the  base  of  the  skull  by  the  second  blow  indicates  the  possibility  of 
producing  a  fatal  lesion  of  the  brain  or  of  its  bloodvessels  by  a  blow 
upon  the  malar  bone. 

General  Summary. — A  fracture  of  the  superior  maxilla  has  occurred 
in  every  instance;  and  twice  when  the  malar  bone  was  not  broken: 
in  each  of  the  two  last  cases  the  antrum  alone  was  broken  and  the 
depression  of  the  malar  bone  was  scarcely  noticeable.  In  the  second 
of  these  cases,  the  fracture  extended  also  through  the  dental  arcade. 

In  three  cases  the  nasal  apophysis  has  broken  near  the  base,  and  in 
one  case  at  two  points.  One  of  the  three  fractures  of  the  nasal  apo- 
physis was  accompanied  with  a  diastasis  of  the  superior  maxilla 
through  its  intermaxillary  suture. 

The  malar  bone  has  been  broken  twice  by  the  first  blow,  and  always 
when  the  blow  has  been  repeated.  The  orbital  margin  and  orbital 
plate  have  been  fissured  twice,  the  outer  portion  of  the  orbital  plate 
being  pushed  a  little  into  the  socket.  Once  this  plate  has  been  pushed 
downwards. 

The  zygoma  has  been  broken  three  times,  and  always  transversely, 
a  little  beyond  its  centre,  or  where  the  bone  is  the  most  slender  and 
most  convex. 

The  ethmoid  has  been  broken  three  times,  and  always  longitudinally 
through  the  orbital  plate. 

The  sphenoid  has  been  broken  once,  at  the  base  of  the  skull. 

In  addition  to  these  observations  upon  the  naked  skull,  I  have  seen 
two  examples,  which  illustrate  the  relative  infrequency  of  fractures  of 
the  malar  bone,  as  compared  with  fractures  of  the  superior  maxilla 


FRACTURES  OF  THE  MALAR  BONE.  107 

and  of  the  other  bones  of  the  face,  even  when  the  blow  is  received 
directly  upon  the  malar  bone. 

Pat.  Maloney,  set,  55,  fell  about  twenty  feet  and  struck  upon  his 
face.  Six  weeks  after  the  accident,  while  an  inmate  of  the  Bu&alo 
Hospital  of  the  Sisters  of  Charity,  I  found  the  right  malar  bone  de- 
pressed, but  I  could  not  trace  any  line  of  fracture  in  the  malar  bone. 
I  think  the  antrum  of  the  superior  maxilla  was  broken  and  the  malar 
bone  forced  in  upon  it. 

Thomas  Crotty,  set.  20,  was  struck  with  a  hoop,  August  15,  1855. 
He  was  seen  immediately  by  a  surgeon  in  Canada,  but  the  fracture 
was  not  recognized.  Five  days  after  he  called  at  my  office.  I  found 
the  outer  portion  of  the  right  malar  bone  lifted  slightly  and  the  lower 
and  anterior  angle  depressed  about  three  lines,  as  if  this  portion  had 
been  forced  in  upon  the  antrum. 

Prognosis. — The  malar  bone  may  be  depressed,  as  we  have  seen,  to 
the  extent  of  two  or  three  lines,  without  being  broken.  This  accident 
will  be  more  properly  considered  under  fractures  of  the  upper  maxilla. 
A  fracture  of  the  malar  bone  implies,  therefore,  generally,  that  great 
force  has  been  applied,  and  that  other  fractures  exist  as  complications. 
This  may  not  be  true,  however,  when  only  the  orbital  margin  of  the 
socket  is  broken.  If  the  orbital  plate  is  broken,  and  a  portion  of  it  is 
pushed  into  the  socket,  it  may  occasion  a  slight  protrusion  of  the  ball, 
as  in  two  cases  related  by  Dr.  Neill  as  fractures  of  the  upper  maxilla, 
and  as  has  been  noticed  in  the  experiments  already  recorded.  This 
protrusion  of  the  eyeball  will  probably  continue  in  some  degree,  as 
long  as  the  bones  remain  displaced.  It  is  quite  probable,  however, 
that  in  some  cases,  after  severe  injuries  of  the  face,  a  moderate  pro- 
trusion of  the  eyeball  is  due  entirely  to  extravasation  of  blood  in  the 
socket ;  a  circumstance  which  would  be  likely  to  follow  a  fracture  of 
the  bones  of  the  socket,  and  to  increase  temporarily  the  protrusion  of 
the  eye. 

If  the  body  of  the  bone  is  broken  entirely  through,  and  coma  super- 
venes upon  the  accident,  there  is  some  reason  to  fear  that  the  skull  is 
fractured  at  its  base,  and  the  prognosis  ought  to  be  grave. 

Treatraent. — If  there  is  only  a  fissure  of  the  orbital  margin,  it  will 
not  require  attention  ;  but  if  the  fissure  extends  through  the  orbital 
plate  and  at  the  same  time  the  anterior  and  inferior  margin  of  the 
bone  is  depressed,  in  consequence  of  which  the  orbital  plate  is  tilted 
upward  and  made  to  push  forward  the  eyeball,  the  propriety  of 
surgical  interference  may  be  considered.  If  this  protrusion  is  con- 
siderable, and  evidently  due  to  the  displaced  bone,  an  attempt  should 
be  made  to  lift  the  body  of  the  malar  bone  and  thus  to  restore  to 
position  its  orbital  plate.  The  method  of  accomplishing  this  I  shall 
describe  particularly  when  speaking  of  fractures  of  the  superior 
maxilla  with  depression  of  the  malar  bones. 


108  FEACTURES    OF    THE    UPPEK    MAXILLARY   BONES. 


CHAPTER    X. 

FRACTURES  OF  THE  UPPER  MAXILLARY  BONES. 

These  fractures  assume  so  great  a  variety  in  respect  to  form,  situa- 
tion and  complications,  that  it  would  be  impossible  to  speak  of  them 
systematically  or  to  establish  anything  but  very  general  rules  as  to 
treatment  and  prognosis. 

They  may  be  broken,  or  loosened  from  each  other  or  from  the  other 
bones  with  which  they  are  articulated,  with  or  without  any  farther 
fracture ;  the  nasal  processes  may  be  broken,  and  generally  this  acci- 
dent is  accompanied  with  a  fracture  of  the  nasal  bones  also ;  the  malar 
bones  may  be  forced  in,  carrying  with  them  a  portion  of  the  outer  wall 
of  the  antrum  ;  the  alveoli  may  be  broken  and  more  or  less  completely 
detached ;  and  either  of  these  several  fractures  may  be  complicated  with 
fractures  of  the  other  bones  of  the  face  or  of  the  base  of  the  skull  even. 

Treatment. — When  the  harmonies  of  the  upper  maxillary  bones  are 
only  slightly  disturbed,  nothing  but  a  retentive  treatment  is  necessary. 

A  man  was  thrown  backward  from  a  loaded  cart,  one  wheel  of  the 
cart  passing  over  his  face.  He  was  taken  up  unconscious,  but  when  I 
saw  him  on  the  following  morning,  his  consciousness  had  returned. 
The  right  malar  bone  was  broken  and  forced  down  upon  the  antrum 
about  three  lines.  Both  superior  maxillae  were  loosened  from  their 
articulations,  and  could  be  moved  laterally,  the  motion  producing  a 
slight  grating  sound.  The  same  motion  and  grating  occurred  when- 
ever he  attempted  to  swallow.  No  effort  was  made  to  elevate  the 
malar  bones,  nor  did  I  find  any  means  necessary  to  retain  the  maxil- 
lary bones  in  place,  the  amount  of  displacement  being  very  incon- 
siderable, and  never  sufficient  to  be  observed  by  the  eye.  Cool  lotions 
were  applied  constantly  to  the  face,  and  the  patient  was  sustained  by 
a  liquid  diet.  On  the  ninth  day  all  motion  of  the  fragments  had 
ceased,  and  on  the  twenty-seventh  day  the  patient  was  completely 
recovered,  with  only  the  depression  of  the  malar  bone  remaining. 

Sargent,  of  Boston,  reports  a  similar  case,  in  which  a  slight  separa- 
tion of  the  maxillary  iDones  united  promptly  and  without  any  retentive 
apparatus.^ 

But  in  a  case  in  which  the  superior  maxillary  bones  had  been  more 
completely  torn  from  their  connections,  complicated  with  other  severe 
injuries,  I  found  it  necessary  to  support  the  fragments  by  closing  the 
lower  jaw  upon  the  upper,  and  by  suitable  bandages.  The  patient 
died,  however,  on  the  twelfth  day.^ 

■  Boston  Med.  and  Surg.  Journ.,  vol.  lii.  p.  378. 

2  Report  on  Deformities  after  Fractures.  Trans.  Amer.  Med.  Association,  vol.  viii. 
p.  375,  Case  IV. 


FRACTURES    OF    THE    UPPER   MAXILLARY   BONES.         109 

Graefe  recommends,  where  the  booes  are  thus  extensively  separated 
and  displaced,  an  apparatus  made  of  steel,  and  suitably  covered,  which 
is  to  be  applied  against  the  forehead  and  buckled  under  the  occiput. 
From  the  two  sides  descend  a  couple  of  steel  plates,  which,  having 
arrived  at  the  free  border  of  the  upper  lip,  are  reflected  upon  them- 
selves, and  are  made  to  support  upon  their  extremities  long  silver 
gutters,  intended  for  the  reception  of  not  only  the  displaced  teeth  and 
alveoli,  but  also  those  teeth  which  are  firm.' 

Wiseman  having  been  summoned  to  a  child  with  his  whole  upper 
jaw  forced  in,  by  the  kick  of  a  horse,  "  beating  the  ethmoides  quite  in 
from  the  os  cribriform,"  and  forcing  the  palate  bone  against  the  back 
of  the  pharynx,  found  great  difficulty  in  securing  a  permanent  read- 
justment. At  first  be  attempted  to  introduce  his  finger  back  of  the 
bone,  but  failing  in  this  he  bent  an  instrument  into  the  form  of  a  hook, 
and  passing  it  between  the  bone  and  the  pharynx,  he  easily  replaced 
the  fragments.  But,  on  removing  the  instrument,  they  were  again 
displaced.  Immediately  he  had  constructed  an  instrument  by  which 
the  bones  could  be  not  only  easily  reduced,  but  also  retained  in  place, 
extension  being  made  by  the  hands  of  the  child,  his  mother  and  others, 
alternately.  In  this  way  the  reunion  was  finally  effected,  and  "  the 
face  restored  to  a  good  shape,  better  than  could  have  been  hoped  for."^ 

Harris,  of  New  York,  mentions  a  case  in  which  a  child,  two  years 
old,  having  fallen  from  a  height  of  fifty  feet  upon  the  pavement,  was 
found  to  have  a  diastasis  of  both  the  superior  maxillary  and  palate 
bones ;  the  separation  being  sufficient  to  admit  the  little  finger,  and 
extending  from  between  the  alveoli  which  supported  the  central  in- 
cisors, to  the  soft  palate.  It  is  not  said  whether  any  efforts  were  made 
to  reduce  the  bones,  but  six  weeks  after  the  injury  was  received,  they 
were  still  open,  and  it  was  proposed  to  close  the  space  by  a  plastic 
operation  as  soon  as  the  condition  of  the  patient  would  warrant  such 
a  procedure.^ 

I  suspect  that  in  this  example,  as  in  the  first  experiment  quoted 
under  fracture  of  the  malar  bone,  it  was  found  impossible  to  adjust 
the  bones  and  close  the  intermaxillary  suture,  and  for  the  same 
reasons. 

If,  in  consequence  of  a  blow  received  upon  the  ossa  nasi,  the  nasal 
processes  of  the  superior  maxillae  are  broken  down,  they  may  be  lifted 
and  adjusted  in  the  same  manner  as  the  ossa  nasi. 

I  have  seen  several  examples  of  this  accident,  and  I  have  in  my 
cabinet  a  specimen,  in  which  the  nasal  bones  being  driven  in  by  the 
kick  of  a  horse,  the  nasal  process  upon  the  left  side  is  broken  off'  just 
above  the  root  of  the  cuspid  tooth,  and  its  upper  end  inclined  inward 
toward  the  nasal  passage  and  backward,  until  it  is  completely  buried. 
In  this  situation  it  has  become  firmly  united  to  the  bony  and  soft 
tissues  into  which  it  was  brought  in  contact. 

The  following  example  will  illustrate  some  of  the  complications  and 

'  Traite  des  Frac,  etc.,  par  L.  F.  Malgaigne,  p.  373. 

2  Chirurgical  Treatises,  by  Richard  Wiseman,  1734,  p.  443. 

^  New  York  Journ.  Med.,  vol.  xiii.,  2d  ser.,  p.  214. 


110  FRACTUEES    OF    THE    UPPER    MAXILLARY    BONES. 

difficulties  connected  with  a  depression  of  the  malar  bone,  and  conse- 
quent fracture  of  the  antrum  maxillare. 

M.  P.,  of  Colesville,  aged  about  34  years,  was  thrown  from  a  height, 
striking  upon  his  face,  forcing  the  right  malar  bone  down  upon  the 
antrum  of  the  superior  maxilla.  Dr.  L.  Potter,  of  Yarysburg,  and 
myself  were  called. 

The  deformity  produced  by  the  sinking  of  the  malar  bone  was 
very  striking,  and  both  the  patient  and  myself  were  very  anxious 
to  have  it  remedied  if  possible.  We  found  some  of  the  teeth  upon 
the  side  of  the  fracture  loose,  and  we  determined  to  extract  them  and 
press  up  the  bone  with  an  instrument  introduced  through  the  empty 
sockets.  The  first  attempt  to  extract  a  molar  tooth,  however,  brought 
down  several  teeth,  and  the  whole  floor  of  the  antrum.  The  detach- 
ment of  this  fragment  was  also  now  so  complete  that  we  believed  it 
necessary  to  remove  it  entirely,  a  labor  which  was  accomplished  with 
infinite  difficulty,  and  with  no  little  hazard  to  the  patient,  as  dissection 
had  to  be  extended  very  far  back  into  the  throat,  and  in  the  end  it 
was  not  effected  without  bringing  out,  attached  to  the  fragment  of 
maxillary  bone,  a  considerable  portion  of  the  pyramidal  process  of  the 
OS  palati. 

The  time  occupied  in  this  operation  was  at  least  one  hour,  during 
which  we  were  every  moment  in  the  most  painful  apprehensions  lest 
we  should  reach  and  wound  the  internal  carotid,  which  lay  in  such 
close  juxtaposition  to  the  knife  that  we  could  distinctly  feel  its  pulsa- 
tion. After  its  removal,  the  hemorrhage  was  for  an  hour  or  more 
quite  profuse,  and  could  only  be  restrained  by  sponge  compresses 
pressed  firmly  back  into  the  mouth  and  antrum. 

When  the  hemorrhage  was  sufficiently  controlled,  we  proceeded  to 
examine  the  antrum,  the  floor  of  which  being  removed  entire,  per- 
mitted the  finger  to  enter  freely.  The  restoration  of  the  malar  bone 
was  now  accomplished  without  much  difficulty,  and  with  only  mode- 
rate force. 

Two  years  after  the  accident,  the  face  presented,  externally,  no 
traces  of  the  original  injury.  The  malar  bone  seemed  to  be  as  promi- 
nent as  upon  the  opposite  side,  and  there  was  no  perceptible  falling 
in  where  the  teeth  and  alveoli  were  removed.  During  several  months 
after  the  removal  of  the  bone,  the  antrum  continued  to  discharge  pus, 
but  at  length  a  semi-cartilaginous  production  closed  in  the  cavity 
below,  entirely  reconstructing  its  floor,  and  the  discharge  ceased. 
Since  then  he  has  experienced  no  further  inconvenience. 

I  wish  to  propose  two  or  three  expedients  for  lifting  the  malar  bone 
when  it  has  been  thrust  down,  which  may  in  certain  cases  be  substi- 
tuted for  the  mode  which  has  been  heretofore  generally  adopted. 

In  many  instances,  no  difficulty  will  be  experienced  in  resorting  to 
the  usual  method.  The  recent  loss  of  one  or  more  teeth  opposite  the 
floor  of  the  broken  antrum,  or  the  complete  displacement  of  a  tooth 
by  the  accident  itself,  will  give  an  opportunity  for  the  perforation  of 
the  antrum  through  the  open  socket,  and  for  the  introduction  of  a 
suitable  instrument  for  lifting  the  depressed  bone.  Unless,  however, 
the  opening  is  quite  large,  the  instrument  employed  must  be  so  small, 


FEACTUEES    OF    THE    UPPEE    MAXILLAEY    BONES.  Ill 

such  as  a  straight  steel  sound  or  a  female  catheter,  as  to  expose  the 
parts  against  which  its  end  is  made  to  press,  to  some  risk  of  being 
broken  and  penetrated.  It  is  even  possible  in  this  way  to  penetrate 
the  socket  of  the  eye,  and  thus  inflict  serious  injury  upon  the  eye 
itself.  Yet,  with  some  care,  such  accidents  may  be  avoided,  and  it  is 
probable  that,  in  the  cases  supposed,  where  the  sockets  of  the  teeth 
opposite  the  base  of  the  antrum  are  open,  this  method  will  continue 
to  have  the  preference. 

But  if  the  teeth  remain  firm  in  their  places,  or  if  they  have  been 
some  time  removed,  and  the  sockets  are  filled  up,  and  we  wish  to  enter 
the  antrum  at  its  base,  we  must  either  drill  through  its  anterior  wall 
above  the  roots  of  the  teeth,  or  we  must  proceed  to  extract  a  tooth. 
The  first  method  gives  an  inconvenient  opening,  and  one  through 
which  it  will  be  necessary  to  use  a  curved  instrument ;  but  yet  it  is  a 
method  far  less  objectionable  than  the  extraction  of  a  tooth  which  is 
firm,  or  which  is  even  tolerably  firm  in  its  socket,  and  which  may 
require  the  forceps  for  its  removal.  The  objections  to  this  latter  pro- 
cedure were  suggested  by  the  tedious  and  painful  operation  already 
detailed.  The  first  attempt  to  extract  a  tooth  brought  down  the  whole 
floor  of  the  antrum,  with  all  its  corresponding  teeth  and  the  pyramidal 
process  of  the  palate  bone.  The  tooth  was  already  loose,  and  we  thought 
it  might  easily  be  taken  out,  but  it  had  not  occurred  to  us  that  it  was 
loosened  by  the  comminuted  condition  of  the  walls  of  the  antrum,  and 
of  the  dental  arcade.  The  experiments  made  upon  the  dead  subject 
would  seem  to  show  that  this  fracture  and  comminution  of  the  alveoli 
is  not  a  very  frequent  result  of  a  fracture  of  the  antrum  produced  by  a 
blow  upon  the  malar  bone,  yet  it  may  happen,  and  whenever  it  does  the 
attempt  to  extract  a  tooth  must  always  expose  the  patient  to  the  same 
hazards.  Certainly  it  is  no  trifling  matter  to  pull  away  all  of  a  man's 
upper  teeth  upon  one  side,  and  to  open  freely  into  a  broad  cavity  which 
might  never  close  again,  and  which,  in  this  event,  must  always  serve 
as  a  place  of  lodgment  for  particles  of  food,  and  for  foul  secretions,  to 
say  nothing  of  the  external  deformity  which  it  is  likely  to  produce, 
and  of  the  severity  and  even  danger  of  the  operation. 

I  wish,  then,  to  suggest  certain  procedures,  the  value  of  which  I  have 
not  yet  had  an  opportunity  to  determine  by  any  experiment  upon  the 
living  subject,  but  which  I  have  carefully  and  frequently  tested  upon 
the  dead. 

First,  we  ought  to  attempt  to  lift  the  bone  by  putting  the  thumb 
under  its  zygomatic  process  and  body  within  the  mouth.  If  the  bone 
is  thrown  directly  downward,  or  downward  and  backward,  this  method 
can  scarcely  fail ;  and  even  when  it  is  thrown  downward  and  forward 
so  as  to  press  into  the  antrum,  it  is  likely  to  succeed.  If,  however, 
for  any  reason,  the  thumb  cannot  be  brought  to  bear  upon  its  under 
surface,  we  may  make  a  small  incision  upon  the  cheek  over  the  ante- 
rior margin  of  the  masseter  muscle,  where  its  insertion  into  the  malar 
bone  terminates,  and  pushing  a  strong  blunt  hook  under  the  bone,  we 
may  lift  it  with  ease. 

Where  the  depression  of  the  malar  bone  is  in  the  direction  of  the 
anterior  and  superior  angle  these  means  may  not  be  found  available. 


112    FRACTUEES  OF  THE  UPPER  MAXILLARY  BONES. 

and  we  may  then  employ  a  screw  elevator,  an  instrument  whicti  I  find 
already  constructed  in  a  case  of  trephining  instruments  made  for  me 
by  Mr.  Liier,  of  Paris,  and  which  I  have  often  used  and  constantly 
recommended  to  my  pupils,  in  certain  cases  of  fractures  of  the  skull. 
The  instrument  ought  to  be  made  of  the  best  steel,  and  with  a  broad, 
sharp-cutting  thread.  A  slight  incision  being  made  through  the  skin, 
and  down  to  the  centre  of  the  malar  bone,  the  elevator  is  then  screwed 
firmly  into  its  structure,  and  now  its  elevation  and  adjustment  may  be 
accomplished  with  the  greatest  ease. 

Malgaigne  remarks:  "In  all  complicated  fractures  of  the  upper 
jaw,  there  is  one  principle  which  surgeons  cannot  too  much  study, 
namely,  that  all  fragments,  however  slightly  adherent  they  may  be, 
ought  to  be  most  carefully  preserved,  and  they  will  be  found  to  unite 
with  wonderful  ease.  This  remark  had  already  been  made  by  Saviard. 
Larrey  insists  strongly  upon  it,  and  we  have  seen  that  M.  Baudens, 
so  great  an  advocate  for  the  removal  of  loose  fragments,  has  declared 
for  these  fractures  a  special  exemption.'" 

Malgaigne  has  here  especial  reference  to  fractures  of  the  dental 
arcade  or  to  fractures  implicating  the  alveoli  and  extending  more  or 
less  into  the  body  of  the  bone. 

It  would  be  an  error,  however,  to  suppose  that  a  reunion  will  in 
these  cases  uniformly  take  place.  Exceptions  have  occurred  in  my 
own  practice,  the  fragments  becoming  loosened  and  completely  de- 
tached after  the  lapse  of  several  weeks.  In  the  case  related  by  Miller, 
the  whole  floor  of  the  antrum  having  been  broken  off,  in  an  unskilful 
attempt  to  extract  the  second  right  upper  molar,  it  was  found  impos- 
sible to  make  it  unite,  and  it  was  subsequently  removed.'  Such 
unfortunate  results  certainly  may  sometimes  be  reasonably  anticipated. 
Yet  they  occur  so  seldom  as  to  justify  the  opinions  and  practice 
advocated  by  Malgaigne. 

In  some  instances,  where  fragments  are  displaced  carrying  with 
them  several  teeth,  while  others  in  the  same  row  remain  firm,  it  will 
be  sufficient  to  close  the  mouth  and  apply  a  bandage  as  for  fracture  of 
the  inferior  maxilla ;  in  others  the  teeth  and  their  alveoli,  ought  to  be 
fastened  with  silk,  or  gold  or  silver  thread ;  or  gold  or  silver  clasps 
may  be  applied,  or  gutta  percha  moulded  to  the  teeth  and  jaw. 

In  a  case  of  fracture  of  the  right  superior  maxilla,  reported  by 
Baker,  of  Norwich,  N.  Y.,  complicated  with  a  fracture  of  the  inferior 
maxilla,  the  alveoli  were  retained  in  place  very  perfectly  by  a  mould 
of  gutta  percha.^  Neill,  of  Philadelphia,  has  also  reported  three  cases 
of  fracture  of  the  bones  of  the  face,  involving  the  superior  maxilla, 
in  two  of  which  the  eyes  were  made  to  protrude  more  or  less  from 
their  sockets.^  The  loosened  alveoli  were  made  fast  by  wire.  The 
subsequent  deformity  was  inconsiderable,  yet  in  no  instance  was  the 
restoration  complete.*     The  same  method  was  adopted  successfully  by 

'  Op.  cit.,  YoL  i.  p.  376.     Paris  ed. 

^  News  Letter,  April,  1854.     Also,  Bost.  Med.  and  Surg.  Joum.,  vol.  li.  p.  246. 
^  New  York  Jouni.  of  Med.,  vol.  i.,  3d  ser.,  p.  362. 

"  See  Observations  first  and  second,  under  Fractures  of  the  Malar  Bone  ;  in  which 
cases  the  orbital  plate  of  the  malar  bone  was  pushed  into  the  sockets. 
°  Phil.  Med.  Exam.,  vol.  x.,  new  ser.,  pp.  455-8. 


FRACTURES    OF    THE    ZYGOiTATIC    ARCH.  113 

a  surgeon  in  Virginia,  in  the  case  of  a  negro  fifty  years  old,  where  most 
of  the  teeth  of  the  left  upper  jaw  were  forced  into  the  mouth,  carrying 
^Yith  them  their  corresponding  alveolar  processes.  The  teeth  remained 
firm  in  their  sockets,  but  the  separation  of  the  bone  was  complete,  the 
fragment  being  held  in  place  only  by  the  raucous  membrane  of  the 
mouth.  On  the  eighth  day  the  surgeon  found  that  the  negro  had 
removed  the  wire,  and  also  the  cork  from  between  his  teeth,  and  the 
maxillary  bandage;  but  the  soft  parts  had  already  united,  and  the 
bones  showed  no  tendency  to  displacement.  His  recovery  was  speedy, 
and  it  was  accomplished  without  any  farther  treatment.^ 


CHAPTER    XI. 

FRACTURES  OF  THE  ZYGOMATIC  ARCH. 

The  zygoma,  strictly  speaking,  is  formed  in  a  great  measure  by  the 
bod}'  of  the  malar  bone,  and  it  is  broken  whenever  the  malar  bone  is 
completely  separated  through  any  portion  of  its  body ;  but  I  propose 
to  confine  my  remarks  to  that  portion  only  which  is  composed  of  the 
two  processes,  called  respectively  the  zygomatic  processes  of  the  malar, 
and  temporal  bones. 

Duverney  relates  a  case  in  which  a  young  child  having  in  his 
mouth  the  end  of  a  lace  spindle,  fell  forwards  and  thrust  the  spindle 
through  the  mouth  from  within  outwards,  breaking  the  zygoma  in  the 
same  direction,  and  leaving  the  fragments  salient  outwards.^  To  which 
case  of  outward  displacement  Packard,  in  a  note  to  Malgaigne's  work 
on  fractures,  &c.,  has  added  a  second.^ 

I  know  of  no  other  examples  in  which  the  fragments  have  been 
thrust  outwards.  A  reference  to  my  experiments  upon  the  naked 
skull  will,  however,  show  that  the  zygoma  may  be  broken  and  dis- 
placed, in  the  same  direction,  by  any  force  which  shall  fracture  the 
superior  maxilla,  and  depress  the  anterior  margin  of  the  malar  bone. 
In  my  experiments  this  has  happened  three  times,  and  always  at  the 
same  point,  viz.,  a  little  beyond  the  middle  of  the  zygoma,  near  where 
the  suture  which  joins  the  two  processes  terminates  below.  The 
fractures  were  always  transverse,  and  not  in  the  line  of  the  suture. 
They  were  therefore  fractures  of  that  portion  of  the  zygoma  which 
belongs  to  the  temporal  bone. 

I  suspect,  also,  that  to  this  class  of  cases  belongs  the  example  re- 
lated by  Dupuytren,  in  which  the  patient  having  died  on  the  fifth  day, 

'  Amer.  Med.  Gazette,  vol.  viii.,  new  ser.,  p.  106. 

'  Bulletin  de  la  Soclete  Anatomique,  p.  138,  ISIO.  ^  Op.  cit.,  p.  289,  vol.  i. 

5 


114  FRACTUEES    OF    THE    ZYGOMATIC    ARCH. 

from  the  effects  of  the  cerebral  concussion,  the  autopsy  disclosed  "a 
fracture  through  the  zygomatic  arch  ;  and  that  part  of  the  superior 
maxillary  bone  which  constitutes  the  antrum  was  driven  in."^ 

In  another  case  mentioned  by  Dupuytren,  produced  by  a  direct 
blow,  the  fracture  was  compound  and  comminuted,  and  although  the 
fragments  were  raised  easily  by  an  elevator,  suppuration  ensued  be- 
neath, and  the  matter  was  discharged  within  the  mouth? 

Tavignot  reports  a  case  of  fracture  of  this  arch  which  was  not  dis- 
covered until  after  death,  the  fragments  not  being  at  all  displaced.^ 

Dr.  John  Boardman,  one  of  the  surgeons  to  the  Buffalo  Hospital  of 
the  Sisters  of  Charity,  informs  me  that  he  has  lately  met  with  a  frac- 
ture of  the  zygoma  in  a  man  about  thirty  years  of  age,  occasioned  by 
a  blow  from  a  cricket  ball.  Dr.  Boardman  saw  him  on  the  fourth  day, 
and  ascertained  that  immediately  on  the  receipt  of  the  injury  he  felt 
slightly  stunned,  and  that  he  soon  recovered  from  this,  but  was  unable 
to  open  his  mouth  except  by  pulling  it  open  with  his  hand ;  neither 
could  he  close  it  except  in  the  same  manner.  This  immobility  of  the 
jaw  continued  several  days  with  only  very  slight  improvement;  at 
the  end  of  five  weeks,  however,  when  last  seen,  the  mobility  was 
nearly,  but  not  quite  restored.  The  depression,  a  little  in  front  of  the 
centre  of  the  zygoma,  was  discovered  by  the  patient  himself  imme- 
diately after  the  receipt  of  the  injury,  and  he  says  he  tried  at  once  to 
ascertain  whether  he  could  not  push  the  fragments  back  by  moving 
the  jaw.  He  was  unable  to  make  any  impression  upon  them  by  this 
manoeuvre.  The  depression  still  remains,  but  it  is  not  so  distinct  as 
it  was  when  first  seen. 

Symptoms. — An  irregular  projection  or  depression  of  the  fragments 
is  the  only  sign  which  can  be  relied  upon  to  indicate  the  existence 
of  this  accident;  and  this  must  often  be  concealed  by  the  swelling, 
which  follows  so  rapidly  wherever  the  integuments  are  severely  bruised 
over  a  superficial  bone.  This  displacement  can  scarcely  occur  in  but 
two  directions,  either  outwards  or  inwards;  since  the  attachments  of 
the  temporal  aponeurosis  above,  and  of  the  masseter  muscle  below, 
must  effectively  prevent  its  descent  or  ascent. 

Neither  motion  nor  crepitus  will  often  be  present.  In  some  few 
cases  the  difficulty  in  opening  or  shutting  the  mouth,  occasioned  by 
the  projection  of  the  fragments  towards  or  into  the  tendon  of  the  tem- 
poral muscle,  may  assist  in  the  diagnosis. 

Prognosis. — If  the  fracture  has  been  produced  indirectly  by  a  de- 
pression of  the  malar  bone,  the  prognosis  must  depend  upon  the  amount 
of  injury  done  to  the  other  bones  of  the  face;  in  itself,  the  fracture  of 
the  zygoma  cannot  be  a  matter  of  any  moment.  The  same  remark 
might  apply  also  to  any  fracture  of  the  zygoma  in  which  the  angles 
were  salient  outwards.  If,  on  the  contrary,  the  angle  is  salient  inwards, 
the  fracture  having  been  produced  by  a  blow  inflicted  directly  upon 
the  zygomatic  arch,  from  without,  or  by  a  blow  upon  the  outer  por- 

'  Injuries  and  Diseases  of  Bones,  by  Baron  Dupuytren.  Syd.  ed.,  London,  1847, 
p.  336. 

•'^  Op.  cit.,  p.  335.  3  Bulletins  de  la  Soc.  Anat.,  1810,  p.  138. 


FEACTUEES    OF    THE    ZYGOMATIC    AECH.  115 

tion  of  the  malar  bone,  it  may,  perhaps,  occasion  some  embarrassment 
to  the  action  of  the  temporal  muscle. 

If  the  force  which  produces  the  fracture  has  acted  more  upon  the 
temporal  portion  of  the  arch,  near  where  the  process  arises  from  the 
temporal  bone,  it  may  be  accompanied  with  a  fracture  of  the  skull, 
and  with  serious  cerebral  lesions,  as  in  one  of  the  cases  already  alluded 
to  as  having  been  noticed  by  Dupuytren. 

The  abscess  which  followed  in  the  case  of  the  compound,  comminuted 
fracture,  quoted  from  the  same  author,  indicates  the  danger  of  this 
complication ;  but  it  must  be  noticed  that  its  evacuation  resulted  in  a 
rapid  cure,  and  that  no  deformity  or  difficulty  in  moving  the  jaw  re- 
mained. 

Treatment. — A  fracture,  accompanied  with  an  outward  displacement, 
and  occasioned  by  a  depression  of  the  malar  bone,  will  be  adjusted  by 
a  restoration  of  the  malar  bone  in  the  manner  already  described,  when 
speaking  of  fractures  of  the  superior  maxillary,  &c.  If  the  fragments 
are  displaced  outwards,  in  consequence  of  a  direct  blow  from  within, 
then  they  may  be  replaced  by  pressing  upon  the  projecting  angle. 
In  this  way  Duverney  easily  reduced  the  bones  in  the  case  which  I 
have  cited. 

When  the  fragments,  in  consequence  of  a  direct  blow  from  without, 
have  been  driven  inwards,  and,  as  a  consequence,  serious  embarrassment 
to  the  motions  of  the  temporal  muscle  ensues,  an  attempt  ought  to  be 
made  at  once  to  replace  them ;  if,  however,  no  impediment  to  the 
action  of  the  muscle  exists,  it  is  scarcely  necessary  to  say  that  no  sur- 
gical interference  will  be  required.  It  is  quite  probable,  indeed,  that 
a  slight  amount  of  embarrassment  may  be  the  result  of  the  direct  in- 
jury to  the  muscle  inflicted  by  the  blow,  without  reference  to  the  dis- 
placement of  the  bone,  and  that  a  few  days  will  suffice  to  remedy  this 
evil  entirely ;  and,  moreover,  experience  teaches  that  in  the  case  of  a 
fracture  in  other  bones,  where  the  fragments  actually  penetrate  the 
muscles  and  remain  thus  displaced,  the  points  are  gradually  absorbed, 
and  rounded,  so  that  after  a  time  they  constitute  no  impediment  to  the 
action  of  the  muscles.  It  is  proper  to  infer  that  the  same  thing  will 
occur  here.  The  surgeon  may  be  reminded,  also,  that  it  is  not  the 
muscle  but  only  its  tendon  which  is  liable  to  be  penetrated,  and  that 
even  this  is  usually  protected  somewhat  by  a  plate  of  soft  adipose 
tissue. 

If  to  these  considerations  we  add  the  difficulties  which  we  shall  be 
likely  to  encounter  in  the  reduction,  we  shall  expect  to  find  but  few 
cases  in  which  a  resort  to  surgical  interference  will  be  necessary. 

Duverney  says  that  he  restored  a  fracture  of  this  arch,  accompanied 
with  depression,  by  pressing  against  the  zygoma  from  within  the 
mouth ;  but  an  examination  of  the  interior  of  the  buccal  cavity  will 
convince  us  that  this  is  impossible  when  the  fracture  is  at  any  point 
near  the  middle  of  the  zygoma,  and  that  it  can  be  only  when  the  frac- 
ture is  at  or  near  the  junction  of  the  zygoma  with  the  body  of  the 
malar  bone  that  any  efiective  pressure  can  be  made  from  this  direction. 
In  such  a  case,  we  may,  perhaps,  lift  the  portion  of  the  zygoma  re- 


116 


FRACTUBES    OF    THE    LOWER    JAW. 


maining  attached  to  the  malar  bone,  by  the  same  means  which  have 
already  been  suggested  for  lifting  the  bone  itself. 

If  the  bone  is  driven  toward  the  tendon  of  the  temporal  muscle  at 
or  near  its  centre,  as  happens  almost  always,  then  if  its  restoration  be- 
comes necessary,  it  can  be  accomplished  only  by  approaching  the  bone 
from  without. 

Dupuytren  found  an  external  wound  through  which,  by  the  aid  of 
a  levator,  he  easily  restored  the  fragments  to  place, 

M.  Ferrier,  however,  of  the  Hospital  of  Aries,  in  a  case  brought 
before  him,  made  an  incision  through  the  integuments  down  to  the 
bone,  and  then  attempted  to  slide  underneath  the  small  extremity  of 
a  spatula ;  but  the  aponeurosis  would  not  yield,  and  he  was  obliged 
to  cut  it  also.  He  was  now  able  to  lift  the  fragments  easily.  The 
wound  healed  rapidly,  and  the  patient  was  dismissed  without  any  de- 
formity.' 


CHAPTER    XII. 


FEACTURES   OF  THE   LOWER  JAW. 

Division. — Of  25  examples  of  fracture  of  this  bone  which  have  come 
under  my  observation,  24  were  broken  through  some  portion  of  the 
body,  namely,  1  perpendicularly  through  the  symphysis;  2  through 
the  symphysis  and  through  the  centre  of  the  body  at  the  same  time;  1 
through  the  angle  and  centre  of  the  body;  1  through  the  body  and 
ascending  ramus;  2  through  the  angle  and  centre  of  the  body  upon 
one  side,  and  through  the  centre  of  the  body  upon  the  opposite  side ; 
5  through  the  angle  only,  and  12  through  the  body  only. 

Of  the  whole  number  11  were  broken  completely  asunder  at  two  or 
more  points,  constituting  double  and  triple  fractures;  and  of  the  re- 
maining 14, 4  were  accompanied  with 
detachment  of  portions  of  the  alve- 
oli, and  1  with  the  detachment  of  a 
considerable  fragment  from  the  base. 
From  this  analysis  it  will  be  seen 
that  15  of  the  25,  or  more  than  one- 
half,  were  comminuted  fractures.  10 
were  compound;  not  to  include  in 
this  enumeration  several  examples 
in  which  the  partial  or  complete  dis- 
lodgment  of  a  tooth,  might  entitle 
them  to  be  called  compound. 


Fig.  24. 


*  Bulletin  des  Sciences  Med.,  torn.  x.  p.  160. 


FEACTUEE3    OF    THE    LOTTEE    JAW.  117 

The  three  fractures  through  or  near  the  sjmpTijsis  were  vertical,  aiid 
eleven  of  the  remainder  were  known  to  be  oblique.  Malgaigne  bas  re- 
marked, also,  that  in  fractures  of  the  body  of  the  bone  the  direction 
of  the  obliquity  is  generally  such  that  the  anterior  fragment  is  made 
at  the  expense  of  the  internal  face  of  the  bone,  and  the  posterior  frag- 
ment at  the  expense  of  the  external  face:  this  latter  overriding  the 
former.  Buck,  of  iSTew  York,  has  seen  the  fragments  in  an  opposite 
condition,  requiring  the  use  of  the  knife  and  the  saw  for  their  extri- 
cation.^ 

In  eighteen  examples  of  fractures  through  the  body,  not  including 
fractures  of  the  symphysis,  the  line  of  fracture  has  been  observed  to  be 
twelve  times  at  or  very  near  the  mental  foramen;  twice  between  the 
first  and  second  incisor;  three  times  behind  the  last  molar,  and  once 
between  the  last  two  molars. 

Syme,  Liston,  and  Miller,  have  remarked,  also,  the  greater  fre- 
quency of  fracture  near  this  foramen,  but  Mr.  Erichsen  thinks  he  has 
seen  it  most  frequently  broken  near  the  symphysis,  between  the  lateral 
incisors  or  between  these  teeth  and  the  canine.  Boyer  observes  that 
it  is  generally  somewhat  in  front  of  the  foramen ;  for  which  reason,  as 
he  thinks,  the  dental  nerve  is  rarely  torn. 

Says  Boyer,  in  his  Traite  des  Maladies  Ghirurgicahs,  "A  fracture 
never  takes  place  in  the  central  point  of  the  length  of  the  jaw,  called 
the  symphysis  of  the  chin;  but  when  the  solution  of  continuity  occurs 
towards  the  middle  of  the  bone,  it  is  upon  one  or  the  other  side  of  the 
symphysis,  which  remains  always  upon  one  of  the  fragments."  An 
opinion  which,  however,  he  does  not  seem  always  to  have  entertained, 
since  Eicherand,  in  a  report  of  his  lectures,  has  made  him  say  that  a 
fracture  sometimes  takes  place  "near  the  chin,  but  seldom  so  as  to 
produce  the  division  of  the  symphysis  of  that  part,  though  it  be  not 
impossible. ''  But  many  surgeons  since  his  time  have  noticed  this 
fracture,  and  Malgaigne  assures  us  that  J.  Cloquet  has  demonstrated 
its  existence  upon  an  anatomical  specimen.  In  the  two  following 
cases  the  evidences  were  so  complete  that  I  do  not  myself  entertain 
much  doubt  as  to  their  character: — 

An  Irish  laborer,  aged  seventeen  years,  was  thrown  from  a  wagon, 
breaking  the  inferior  maxilla  on  both  sides  through  the  bod}'-,  and, 
also,  exactly  in  the  centre,  vertically,  between  the  central  incisors. 

I  dressed  the  jaw  with  a  four-tailed  bandage,  but  found  great  diffi- 
culty in  bringing  up  the  left  fragment  to  a  line  with  the  right.  I 
therefore  closed  the  jaws ;  but  finding  that  the  left  side  still  fell  three 
lines  below  the  right,  I  placed  a  pine  wood  wedge  between  the  teeth 
on  the  right  side,  and  drew  the  inferior  maxilla  up  firmly.  It  now 
lacked  only  about  half  a  line  of  being  in  place. 

There  did  not  appear  to  be,  after  this,  much  difficulty  in  maintaining 
quiet  and  apposition  of  the  fragments;  and  I  supposed,  from  repeated 
examinations,  that  they  were  in  exact  line,  until  four  weeks  after  the 
fracture  had  occurred,  when  I  discovered  that  the  central  fi-agments 

'  Xe-^  York  Joum.  Med.,  ilarcli,  1S47.  Proceedings  of  N.  Y.  Med.  and  Surg,  Soc, 
Sept.  19,  1846. 


118  FRACTUEES    OF    THE    LOWER   JAW. 

were  lifted  about  two  lines  above  the  lateral,  and,  also,  slightly  carried 
back ;  and  althougb  union  had  not  taken  place,  yet  they  could  not  be 
replaced  by  any  moderate  force.  The  bones  united  with  this  slight 
deformity.  Four  days  later  no  motion  was  perceptible,  and  the  dis- 
placement seemed  to  be  rather  less.  From  this  time  the  dressings 
were  discontinued. 

A  gentleman,  aged  twenty-five  years,  had  his  inferior  maxilla  broken 
by  the  kick  of  a  horse.  The  left  lateral  incisor  was  completely  dis- 
placed, and  a  large  piece  of  the  dental  arcade  detached. 

Dr.  S.  Gr.  Ellis,  of  Gowanda,  N.  Y.,  dressed  the  fracture,  securing 
the  loosened  fragment  by  the  main-spring  of  a  watch,  made  fast  to  the 
teeth  by  a  silver  wire,  and  closing  the  mouth  completely,  without  any 
interdental  splint.  Upon  the  outside  he  placed  a  pasteboard  splint 
and  bandages.  On  the  fourth  week  a  fragment  exfoliated,  and  came 
out  under  the  chin.     The  union  was  delayed  some  six  or  eight  weeks. 

I  examined  the  jaw  ten  years  after  it  was  broken,  and  found  the 
line  of  a  vertical  fracture  exactly  through  the  symphysis  menti.  The 
left  half  of  the  chin  was  slightly  elevated,  and  the  whole  of  that  side 
of  the  shaft  was  smaller  than  the  right.  He  could  not  close  his  teeth 
perfectly,  yet  he  could  close  them  sufficiently  for  the  purposes  of 
mastication. 

Stephen  Smith,  of  New  York,  has  seen  two  examples,^  Lonsdale 
mentions  three,^  and  Gibson  has  seen  one.'' 

One  ought  not  to  be  too  confident,  however,  of  the  exact  line  of  the 
fracture  unless  its  existence  can  be  demonstrated  upon  the  naked  bone, 
since  a'  slight  deviation  to  the  one  side  or  the  other  of  the  symphysis 
might  not  be  easily  detected  in  the  living  subject. 

Yelpeau,  Fergusson,  Gibson,  Henry  Smith  and  others,  have  re- 
marked that  a  separation  at  the  symphysis  takes  place  usually  in  in- 
fancy or  childhood.  But  in  the  eight  examples  in  which  I  find  the  ages 
reported,  only  one,  a  case  mentioned  by  Lonsdale,  occurred  in  a  person 
as  young  as  ten  years ;  in  one  of  the  cases  seen  by  myself  the  patient 
was  seventeen  years  old,  and  the  remainder  have  ranged  from  twenty- 
five  years  to  sixty :  and  the  average  age  of  all  is  thirty -two  years. 

I  have  seen  one  example  of  a  fracture  of  the  ramus,  in  a  man  twenty- 
three  years  old,  who  had  been  struck  by  a  wooden  block  on  the  side 
of  his  face.  The  ramus  was  broken  just  above  the  angle,  and  the 
body  was  broken,  also,  obliquely  near  the  symphysis.  The  intercepted 
fragment  was  carried  inwards.''  Ledran  mentions  the  case  of  a  child, 
ten  or  twelve  years  old,  in  whom  the  fracture  was  double  also;  one 
fracture  having  taken  place  through  the  body,  and  one  extending 
obliquely  from  the  root  of  the  coronoid  process  to  the  neck  of  the 
condyle.  The  intercepted  fragment  was,  however,  so  little  displaced 
that  the  fracture  of  the  ramus  was  not  discovered  until  after  death.^ 

'  New  York  Journ.  Med.,  Jan.  1857,  Hospital  Reports. 

^  Practical  Treatise  on  Fractures.     By  Edward  F.  Lonsdale.     London,  1838,  p.  226. 
3  Institutes  and  Practice  of  Surg.     By  Wm.  Gibson.     Philadelphia,  1841,  p.  261. 
"•  Trans.  Amer.  Med.  Assoc.     Report  on  "  Deformities  after  Fractures,"  vol.  viii.  p. 
385,  Case  17. 

^  Malgaigne,  op.  cit.,  p.  377,  from  Ledran,  Observ.  Chirurg.,  torn.  i.  obs.  viii. 


FEACTURES    OF    THE    LOTVEE    JAW.  119 

Malgaigne  refers  to  this  as  the  only  example  recorded ;  but  Stephen 
Smith,  of  the  Bellevue  Hospital,  has  met  with  it  four  times ;  in  one 
case  the  ramus  was  broken  on  both  sides ;  in  two  cases  one  ramus 
only  was  broken ;  and  in  one  the  body  was  broken  on  the  right  side 
and  the  ramus  on  the  left.''  In  two  of  these  examples  the  fragments 
were  not  displaced. 

The  coronoid  process  is  so  well  protected  by  muscles  and  by  the 
surrounding  bony  projections,  that  it  is  very  rarely  broken. 

Houzelot  mentions  a  case  in  which  a  fall  from  a  height  produced  at 
the  same  time  a  fracture  of  both  condyles,  of  both  coronoid  processes 
and  of  the  symphysis.^ 

With,  this  single  exception,  I  am  not  able  to  find  a  recorded 
example  of  a  fracture  of  this  process. 

At  least  nine  cases  have  been  reported  of  fracture  of  the  condyles, 
in  all  of  which  the  separation  occurred  through  the  neck,  viz.,  three 
by  Eibes,  two  by  Desault,  one  by  B^rard,  one  by  Houzelot,  one  by 
Bichat,  one  by  Packard,  of  Philadelphia,  and  two  by  Watson,  of  N.  Y. 
The  fracture  alwaj's  occurring  through  the  neck  and  just  below  the 
insertion  of  the  external  pterygoid  muscle. 

According  to  Malgaigne,  the  analysis  of  these  cases,  excepting  those 
mentioned  by  Packard  and  Watson,  shows  two  classes  of  examples : 
the  one  occasioned  by  falls  or  blows  upon  the  chin,  and  producing  a 
simple  fracture  of  the  neck  of  the  condyle ;  the  other,  occasioned  by 
injuries  inflicted  upon  the  side  of  the  face,  and  producing  a  fracture  of 
the  neck  on  the  side  corresponding  to  that  upon  which  the  injuries 
are  received,  and  at  the  same  time  a  fracture  of  the  body  upon  the 
opposite  side.     These  two  varieties  seem  to  be  about  equally  common. 

In  the  case  mentioned  by  Houzelot,  and  already  cited,  there  existed 
at  the  same  time  a  fracture  of  both  condyles,  of  both  coronoid  pro- 
cesses and  at  the  sj^mphysis.  The  man  also  whom  Watson  saw  in 
the  New  York  Hospital,  had  fallen  from  the  yard-arm  of  a  vessel, 
breaking  his  thigh  and  arm  bones  and  both  condyles  of  the  lower  jaw, 
"  His  face  was  somewhat  deformed  by  the  retraction  of  the  chin  ;  the 
mouth  could  not  be  opened  so  as  to  protrude  the  tongue  to  any  great 
extent  beyond  the  teeth,  and  the  teeth  of  the  upper  and  lower  jaw 
could  not  be  brought  into  contact.  In  attempting  to  move  the  jaw 
the  patient  experienced  pain  and  crepitation  just  in  front  of  the  ears; 
the  crepitation  could  easily  be  felt  by  placing  the  fingers  over  the 
fractured  condyles,  JSTothing  was  done  for  the  fractures  of  the  jaw. 
In  a  few  weeks  the  rubbing  of  the  broken  surfaces  and  attendant  sore- 
ness ceased  to  trouble  him  ;  but  the  shape  of  the  jaw  and  difficulty  of 
opening  the  mouth,  to  any  great  extent,  still  remained  unaltered."^ 

Etiology. — The  causes,  in  such  cases  as  I  have  myself  investigated, 
seem  generally  to  have  been  direct  blows,  in  most  instances  inflicted 
by  a  club,  or  by  the  kick  of  a  horse;  in  one  instance  the  blow  was 
inflicted  by  the  fist.     I  have  also  seen  a  fracture  immediately  in  front 

'  New  York  Joum.  Med.,  Jan.  1857.     Bellevue  Hosp.  Reports. 

^  Malgaigne,  op.  cit.,  p.  400. 

^  Nevr  York  Journ.  of  Med.,  Oct.,  1840,    Hospital  Reports, 


120  FEACTUEES    OF    THE    LOWEE    JAW. 

of  the  right  cuspid,  in  a  lad  eight  years  of  age,  produced  by  being 
pressed  between  two  wagons,  the  pressure  being  made  upon  the  two 
angles  of  the  jaw.  In  ten  of  eleven  cases  mentioned  by  Stephen  Smith, 
the  causes  were  direct  blows.  Examples  of  fracture  of  the  inferior 
maxilla  from  indirect  blows  have,  however,  been  mentioned  by  other 
surgeons,  the  angles  of  the  bone  being  pressed  together  by  the  pas- 
sage of  a  wheel,  and  the  fracture  taking  place  usually  towards  the 
symphysis. 

We  have  already  alluded  to  the  observation  of  Malgaigne,  that  frac- 
tures of  the  condyles  belong  to  two  classes :  the  one  being  occasioned 
by  falls  upon  the  chin,  and  the  other  by  blows  upon  the  side  of  the 
face :  the  former  acting  as  a  counter  force  and  the  latter  as  a  direct. 

The  coronoid  process  can  only  be  broken  by  a  direct  blow. 

Sym'pto'ms. — Fractures  of  the  body  of  the  bone  are  characterized  by 
the  usual  signs  of  fracture  elsewhere,  namely,  displacement,  mobility, 
crepitus,  and  pain. 

The  displacement  is  generally  present ;  but  its  direction  and  amount 
vary  accoixling  to  the  situation  and  course  of  the  fracture,  and  also 
according  to  the  violence  and  direction  of  the  force  producing  the 
fracture.  In  one  instance  the  displacement  did  not  exist,  and  indeed 
I  think  it  ought  to  be  regarded  as  an  example  of  a  partial  fracture. 

A  lad,  93t.  9,  was  kicked  by  a  horse  on  the  22d  of  June,  1858,  the 
blow  being  received  on  the  right  side  of  the  jaw.  I  saw  him  very 
soon  after  the  accident,  but  could  not  detect  any  fracture,  only  the 
body  of  the  jaw  seemed  to  be  bent  in.  On  the  third  day,  however, 
while  'endeavoring  to  straighten  the  jaw  by  violent  pressure  from 
within  outwards  I  detected  a  feeble  crepitus,  which  on  more  careful 
examination  proved  to  be  opposite  the  second  incisor  of  the  right 
side.  I  was  also  able  to  detect  a  slight  motion  at  the  same  point.  It 
was  found  impossible  to  rectify  the  bending,  and  no  further  efforts 
were  employed.  At  this  moment,  after  a  lapse  of  nearly  a  year,  the 
natural  curve  is  partially  but  not  completely  restored. 

Ledran  and  other  surgeons  have  also  seen  examples  where  neither 
the  periosteum  nor  mucous  membrane  was  torn. 

Generally,  in  fractures  of  the  body,  the  anterior  fragment  is  de- 
pressed ;  and  Malgaigne  affirms  that  where  an  overlapping  occurs, 
the  anterior  fragment  lies,  generally,  within  the  posterior;  a  fact 
which  he  explains  by  the  direction  which  the  line  of  fracture  usually 
takes,  namely,  from  without,  inwards  and  backwards,  as  we  have 
already  mentioned.  In  one  instance,  reported  by  me  to  the  Amer. 
Med.  Assoc,  where  the  jaw  was  broken  at  the  symphysis  and  also  on 
both  sides  through  the  body,  the  central  fragments  were  found,  after 
about  four  weeks,  lifted  two  lines  above  the  lateral  fragments,  and  also 
slightly  carried  backwards.^  I  have  twice  also  met  with  examples  in 
which  the  posterior  fragments  were  inclined  to  fall  inwards  toward 
the  mouth,  a  circumstance  which  seemed  to  indicate  that  the  course  of 
the  obliquity  was  in  a  direction  opposite  to  that  which  Malgaigne  has 
observed  to  be  most  frequent.     In  each  of  these  examples  the  jaw  was 

•  Trans.  Amer.  Med.  Assoc,  vol.  viii.  p.  380,  1855,  Case  6. 


FRACTURES    OF    THE    LOWER    JAW.  121 

broken  upon  both  sides,  bj  blows  inflicted  with  a  club,  and  the  frac- 
tures were  situated  well  back.'  It  is  possible,  however,  that  the  posi- 
tion of  the  fragments  was  due  rather  to  the  direction  and  force  of  the 
impression  than  to  the  direction  of  the  line  of  fracture. 

As  to  the  action  of  the  muscles  in  the  production  of  displacement, 
Boyer,  S.  Cooper,  Erichsen,  and  Malgaigne,  have  observed  that  their 
action  upon  the  anterior  fragment  is  greater  in  proportion  as  the  frac- 
ture is  nearer  the  symphysis,  and  less  in  proportion  as  it  approaches 
the  angle.  So  that  in  the  former  case  the  attempt  to  close  the  mouth 
is  sometimes  attended  with  a  depression  of  the  anterior  fragment, 
causing  a  separation  of  the  fragments  at  their  alveolar  margins ;  while 
in  the  latter  case,  the  attempt  to  close  the  mouth  forcibly  is  occasion- 
ally attended  with  separation  of  the  fragments  along  the  line  of  the 
base. 

While  I  am  not  prepared  to  deny  the  accuracy  of  these  observations, 
it  is  proper  to  notice  that  Liston  finds  the  greatest  displacement  when 
the  fracture  is  opposite  the  first  molar,  and  I  must  confess  that  the  fact, 
as  stated  by  Boyer  and  others,  does  not  seem  to  admit  of  a  satisfactory 
explanation ;  since  the  number,  and  consequently  the  power  of  the 
muscles  which  act  upon  the  anterior  fragment  from  below,  is  greatest 
at  a  point  considerably  remote  from  the  symphysis.  These  muscles, 
namely,  the  digastricus,  the  genio-hyo-glossus,  and  the  mj^lo-hyoideus, 
with  several  other  muscles  which  act  less  directly,  all  tend  to  depress 
the  anterior  fragment,  and  in  some  slight  degree  to  carry  it  backwards, 
a  direction  which,  indeed,  it  usually  takes,  and  which  it  would  pro- 
bably always  take  if  left  alone  to  the  action  of  the  muscles.  If  the 
fracture  has  occurred  through  the  angle,  or  at  any  point  within  the 
attachments  of  the  masseter  muscle,  the  action  of  those  fibres  of  this 
muscle  which  remain  connected  with  the  anterior  fragment  will  suffi- 
ciently explain  the  fact  that  it  is  not  now  so  easily  depressed  below 
the  level  of  the  posterior  fragment ;  while  the  separation  of  the  frag- 
ments along  the  line  of  the  base  when  an  attempt  is  made  to  close 
the  jaw  forcibly,  is  probably  due  to  the  loosening  and  partial  dislodg- 
ment  of  some  of  the  molars,  which,  being  pressed  upwards,  act  as  a 
pivot  upon  which  the  fragments  are  made  to  bend. 

Boyer  affirms,  also,  that  "  the  fractured  portions  are  never  deranged 
so  as  that  one  passes  on  the  other,  or  in  the  direction  of  their  length; 
for  the  action  of  none  of  the  muscles  of  the  lower  jaw  is  parallel  to 
the  axis  of  that  bone;  besides,  its  extremities  are  retained  in  the 
glenoidal  cavities  of  the  temporal  bones."  But  this  theory  is  too  ex- 
clusive, since  the  fragments  may  have  become  displaced  in  any  direc- 
tion independently  of  the  muscular  action.  Moreover,  the  action  of 
the  muscles  attached  to  the  anterior  fragment,  although  not  parallel  to 
the  axis  of  the  bone,  does  somewhat  favor  a  displacement  in  this 
direction ;  and  the  action  of  the  pterygoid  muscles  upon  the  posterior 
fragment  still  farther  favors  this  form  of  displacement. 

An  overlapping  of  the  fragments  in  the  direction  of  the  axis  is,  no 
doubt,  exceptional,  and  in  such  examples  as  I  have  seen,  it  was  very 

'  Ibid.,  Cases  1  and  10. 


122  FRACTUEES    OF    THE    LOWER   JAW. 

trivial.  It  occurred  in  case  "  three"  of  my  "  Report,"  the  fracture 
being  near  the  mental  foramen;  in  case  "two,"  the  fracture  being 
just  anterior  to  the  last  molar;  and  also  in  case  "six,"  where  the  bone 
had  been  broken  through  the  centre  of  the  body  on  both  sides  and 
through  the  symphysis ;  but  in  neither  case  did  the  overlapping  exceed 
two  or  three  lines,  and  it  was  always  easily  overcome. 

The  mobility  of  the  fragments  is  not  so  striking  in  these  accidents 
as  in  fractures  of  the  long  bones,  yet  it  is  generally  sufficiently  marked, 
and  especially  where  the  bone  is  broken  upon  both  sides  at  the  same 
time.  If  only  one  side  is  broken,  both  motion  and  crepitus  will  be 
most  easily  detected  by  lateral  pressure  upon  the  posterior  fragment, 
which,  being  the  smallest  and  the  least  supported  by  antagonizing 
muscles,  will  be  found  to  be  the  most  movable.  If  the  fracture  is 
upon  both  sides,  mobility  and  crepitus  will  be  most  readily  developed 
by  seizing  upon  the  anterior  fragment  and  moving  it  gently  up  and 
down,  while  the  finger  rests  upon  the  alveolus  within  the  mouth. 

Sometimes  a  slight  swelling  or  tenderness  at  some  point  of  the 
dental  arcade,  or  the  loosening  or  complete  dislodgment  of  a  tooth, 
will  indicate  the  point  of  fracture. 

Pain,  especially  when  the  fragments  are  moved,  is  here  more  con- 
stant than  in  most  other  fractures,  owing,  perhaps,  in  part  to  the 
superficial  position  of  the  bone  which  renders  the  soft  parts  lying  over 
it  more  liable  to  injury  from  the  causes  of  fracture;  but  also,  in  part, 
to  the  lesions  which  the  inferior  dental  nerve  may  have  suffered.  It 
is,  indeed,  a  matter  of  surprise  that  injury  to  this  nerve  does  not 
oftener  seriously  complicate  these  accidents,  coursing,  as  it  does, 
through  so  large  a  portion  of  the  angle  and  body  of  the  bone.  One 
might  naturally  suppose  that  its  complete  disruption  would  often 
occasion  paralysis  of  those  portions  of  the  face  to  which  it  is  finally 
distributed,  and  that  its  partial  lesions  and  contusions  would  create, 
in  many  cases,  the  most  acute  and  constant  suffering.  It  is  rare,  how- 
ever, that  we  have  present  an  amount  of  pain  which  might  not  be 
attributed  to  a  severe  shock,  or  a  slight  strain  upon  its  fibres.  I  have 
myself  never  seen  any  extraordinary  suffering  distinctly  attributable 
to  an  injury  of  the  dental  nerve  after  fracture,  nor  any  degree  of  facial 
paralysis.  Rossi  relates  a  case  in  which  convulsions  followed  this 
accident,  and  in  which,  as  a  final  remedy,  he  proposed  to  expose  and 
bisect  the  nerve ;  and  Flajani  saw  a  patient  whose  jaw  had  been 
broken,  die  in  convulsions  on  the  tenth  day,  the  muscular  contractions 
having  commenced  as  early  as  the  fourth  day  after  the  accident.  The 
autopsy  disclosed  a  rupture  of  the  dental  nerve,  but  no  injury  to  the 
brain. 

These  two  examples  are,  as  far  as  I  know,  all  which  our  records 
supply,  in  which  grave  results  have  been  attributed  to  lesions  of  this 
nerve ;  and  even  here  some  doubt  must  remain  whether  the  symptoms 
were  not  quite  as  much  due  to  the  immediate  injury  done  to  the  brain 
as  to  the  nerve. 

Boyer  explained  the  infrequency  of  severe  injury  to  the  dental 
nerve  by  the  supposition  that  tlie  "greater  part  of  these  fractures  takes 


FRACTUEES    OF    THE    LOWER   JAW.  123 

place  between  the  symphysis  and  the  foramen  by  which  this  nerve 
comes  out."  An  opinion  which  may  be  correct,  but  needs  confirmation. 
I  have  seen  the  body  or  angle  broken  at  points  posterior  to  the  mental 
foramen,  and  where  the  nerve  lies  within  its  bony  canal,  twelve  times, 
and  in  front  of  the  mental  foramen,  eight  times,  and  twelve  times  the 
point  of  fracture  has  not  been  stated  with  such  accuracy  as  to  enable 
me  to  say  whether  it  was  in  front  of  or  behind  the  foramen ;  of  these 
latter,  ten  were  said  to  be  near  the  foramen. 

I  suspect  that  a  better  explanation  may  be  found  in  the  fact  that 
the  fragments  seldom  overlap,  to  any  appreciable  extent,  and  that  even 
the  displacement  in  the  direction  of  the  diameters  of  the  bone  is  gene- 
rally inconsiderable,  or  if  it  does  exist  it  is  easily  and  promptly  re- 
placed. 

If  the  displacement  is  sufficient  to  occasion  a  complete  disruption 
of  the  nerve,  some  degree  of  temporary  paralysis  in  the  portions  of 
the  face  supplied  by  it  must  be  inevitable ;  and,  perhaps,  this  occurs 
oftener  than  it  has  been  noticed,  since,  during  the  confinement  of  the 
jaw  by  dressings,  it  is  not  likely  to  be  observed,  and  after  the  lapse  of 
a  few  weeks  it  will  probably  cease  altogether. 

Boyer  remarks  that  when  it  is  torn,  "the  square  and  triangular 
muscles  of  the  chin  are  paralyzed.  The  skin  of  that  part  and  the  in- 
ternal membrane  of  the  under  lip  preserve  their  sensibility,  which  it 
appears  they  owe  to  some  threads  of  the  portio  dura  of  the  seventh 
pair ;  but  the  paralysis  of  these  muscles  does  not  prove  of  itself  that 
the  jaw  is  fractured."  Boyer  has,  however,  noticed  this  result  but 
once,  and  then  in  a  case  where  the  bone  was  broken  upon  both  sides 
and  the  soft  parts  greatly  contused.  The  triangular  and  square  mus- 
cles were  paralyzed,  in  consequence  of  which  there  was  a  slight  con- 
tortion of  the  mouth.  A.  B(^rard  has  also  mentioned  a  case  of  vertical 
fracture  occurring  between  the  second  and  third  molars,  without 
displacement,  which  was  accompanied  with  complete  insensibility  of 
the  lip  on  the  same  side  throughout  the  space  comprised  between  the 
commissure  and  the  median  line,  and  between  the  free  border  of  the 
lip  and  the  chin.     The  paralysis  disappeared  after  a  few  days.' 

To  these  signs  now  enumerated,  we  may  add  as  occasional  compli- 
cations, rather  than  as  diagnostic  symptoms,  salivation,  swelling  of  the 
submaxillary  and  sublingual  glands,  abscesses,  necrosis,  &c.  If  the 
blow  has  been  vertical  upon  the  chin,  and  the  direction  of  its  force 
has  been  towards  the  articulations,  the  bony  structure  of  the  ear,  and 
even  the  brain  may  have  suffered  serious  lesions,  which  may  be  in- 
dicated by  a  deafness,  or  a  roaring  in  the  ears,  by  bleeding  from  the 
external  meatus,  and  by  fatal  coma.  Tessier  saw  a  man  who  had  re- 
ceived the  kick  of  a  horse  exactly  upon  the  centre  of  the  chin,  breaking 
the  bone  on  both  sides,  and  who,  in  consequence,  bled  freely  from  his 
eajs;^  and  Alix  relates  the  case  of  a  young  man  who,  falling  from  a 
height  and  striking  upon  his  chin,  had  broken  his  jaw.     Insensibility 

'  Malgaigne,  from  Gazette  des  Hopitaux,  10  Aout,  1841. 

2  Malgaigne,  p.  383  and  386  ;  from  Journ.  de  Med.,  1789,  torn.  Ixxix.,  p.  246. 


124:  FRACTUEES    OF    THE    LOWER    JAW. 

immediately  followed ;  convulsions  also  ensued  upon  the  fourth  day, 
and  he  died  upon  the  sixth.^ 

If  the  fracture  is  at  the  symphysis,  it  is  generally  vertical,  and  either 
fragment  may  be  found  slightly  displaced  upwards  or  downwards. 
In  one  of  the  examples  seen  by  myself,  the  left  fragment  fell  three 
lines  below  the  right,  and  in  another  the  right  side  had  fallen  about 
one  line.  In  a  case  mentioned  by  Syme  there  was  scarcely  any  dis- 
placement.^ Liston  remarks  that  it  is  usually  slight.  Erichsen  and 
B.  Cooper  have  observed  the  same. 

The  signs  which  indicate  a  fracture  through  the  angle  have  already 
been  sufiiciently  considered  when  speaking  of  fractures  of  the  body; 
from  which  it  only  differs  in  the  less  degree  of  displacement,  and  in 
the  fact  that  the  posterior  fragments  are  a  little  more  prone  to  fall  in- 
wards toward  the  mouth.  I  have  noticed,  also,  that  owing  probably 
to  the  loosening  and  partial  dislodgment  of  the  last  molar,  it  is  some- 
times difficult  to  close  the  mouth,  the  same  as  in  the  fractures  a  little 
farther  forwards. 

In  the  only  example  of  fracture  of  the  ascending  ramus  which  I 
have  seen,  the  bone  being  broken  also  through  its  body,  the  fracture 
of  the  ramus  was  easily  recognized  by  both  crepitus  and  mobility. 

As  to  the  signs  which  indicate  a  fracture  of  the  coronoid  process,  I 
am  only  able  to  infer  them  from  its  anatomical  relations.  There  must 
be  some  embarrassment  in  the  motions  of  the  jaw,  occasioned  by  the 
detachment  of  a  portion  of  the  fibres  of  the  temporal  muscle;  and  it  is 
probable  that  an  examination  by  the  finger,  within  the  mouth,  would 
readily  detect  mobility  and  displacement. 

A  fracture  through  the  neck  of  the  condyle  is  characterized  by  pain 
at  the  seat  of  fracture,  especially  recognized  when  an  attempt  is  made 
to  open  or  shut  the  mouth,  by  embarrassment  in  the  motions  of  the 
jaw,  by  crepitus,  which  may  usually  be  felt  or  heard  by  the  patient 
himself,  by  mobility  and  displacement. 

The  upper  fragment,  if  disengaged  from  the  lower,  is  drawn  for- 
wards, upwards,  and  inwards,  by  the  action  of  the  pterygoideus  exter- 
nus;  and  it  is  felt  not  to  accompany  the  movements  of  the  lower 
fragment. 

The  lower  fragment  is  at  the  same  time  drawn  upwards,  in  conse- 
quence of  which  the  lower  part  of  the  face  is  distorted:  a  circum- 
stance first  noticed  by  Ribes,  and  which  supplies  an  important 
diagnostic  mark  between  a  fracture  of  one  condyle  and  a  dislocation. 
In  dislocation,  the  chin  is  commonly  thrown  to  one  side,  but  it  is  to 
the  side  opposite  that  on  which  the  dislocation  has  occurred,  while  in 
fracture  the  chin  is  drawn  to  the  same  side. 

Prognosis. — Physick,  of  Philadelphia,  saw  a  case  of  non-union  of 
the  body  of  this  bone,  which  had  existed  nine  months.^  Dupuytren 
mentions  a  case  which  had  existed  three  years."*  Horeau  has  recorded 
one  example  in  a  man  who  had  received  a  gunshot  wound  through 

'  Malgaigne,  p.  386;  from  Alix,  Observata  Chir.,  fascic.  1,  obs.  10. 

*  Amer.  Journ.  Med.  Sci.,  vol.  xviii.  p.  243. 

3  Phila.  Med.  aud  Surg.  Journ.,  vol.  v.  *  Le5ons  Orales. 


FRACTURES    OF    THE    LOWER    JAW.  125 

his  face.^  Stephen  Smith,  of  New  York,  reports  a  case  of  fracture 
of  both  the  body  and  ramus,  in  a  man  forty -five  years  old.  The  severity 
of  the  injury,  with  the  supervention  of  delirium  tremens,  prevented  the 
application  of  dressings  until  the  thirteenth  day.  On  the  twentieth 
day  about  a  pint  of  blood  was  lost  by  hemorrhage  from  the  seat  of 
fracture.  He  remained  in  the  hospital  one  hundred  and  thirty-seven 
days,  and  was  finally  discharged,  the  fragments  not  having  yet  united,^ 
Malgaigne  says  that  Boyer  has  seen  several  examples,  but  I  know  of 
no  other  cases  which  have  been  recorded.  In  no  instance  under  my 
observation,  has  the  bone  refused  finally  to  unite,  although  I  have 
seen  the  union  delayed  six,  seven,  ten,  and  even  eleven  weeks  or  more.^ 
In  three  of  these  cases  the  fractures  were  either  compound  or  commi- 
nuted; but  in  one  case  the  fracture  was  simple,  the  delay  in  the  union 
being  due  to  a  feeble  condition  of  the  system,  and  in  part,  perhaps,  to 
neglect  of  proper  treatment. 

The  infrequency  of  non-union  after  this  fracture,  is  a  fact  worthy 
of  especial  attention,  because  of  the  extreme  difficulty,  if  not  actual 
impossibility,  in  many  cases,  of  preventing  motion  between  the  frag- 
ments, by  any  mode  of  dressing  yet  devised.  Any  one  who  has  ob- 
served attentively,  must  have  seen,  not  only  that  his  dressings  are 
more  often  found  disturbed  and  loosened,  than  in  the  case  of  almost 
any  other  fracture,  unless  it  be  the  clavicle,  and  thus  the  fragments 
have  been  through  all  the  treatment  subjected  to  frequent  changes  of 
position ;  but,  also,  that  even  while  the  dressings  remain  snugly  in 
place,  the  patient  seldom  is  able  to  perform  the  necessary  acts  of  deg- 
lutition, or  to  speak,  even,  without  inflicting  some  motion  upon  the 
fragments. 

Indeed,  the  rapidity  as  well  as  certainty  with  which  this  bone  unites, 
has,  I  think,  been  observed  by  other  surgeons,  and  I  have  myself 
noticed  one  instance,  in  an  adult  person,  in  which  the  bone  was  immo- 
vable at  the  seat  of  fracture,  on  the  seventeenth  day,  and,  perhaps, 
earlier.  In  other  instances,  the  union  has  been  speedily  effected  after 
the  removal  of  all  dressings. 

The  amount  of  deformity  resulting,  also,  from  these  fractures  is 
usually  very  trifling,  whatever  treatment  has  been  adopted.  Ten  of 
the  twenty-five  examples  seen  by  me,  are  recorded  as  resulting  in 
some  degree  of  imperfection,  but  one  of  these  cases  was  complicated 
with  other  injuries,  of  which  the  patient  died  in  a  few  days,  and  one 
was  a  case  of  delayed  union.  Only  eight  of  the  united  fractures  are 
imperfect,  and  in  none  of  these  is  the  imperfection  such  as  to  be  no- 
ticed in  a  casual  examination  of  the  face.  The  deformity  which  is 
usually  found,  is  a  slight  irregularity  of  the  teeth,  produced,  in  most 
cases,  by  a  falling  of  the  anterior  fragment,  but  in  one  case  by  a  slight 
elevation  of  the  anterior  fragment.  But  even  this  does  not  always 
interfere  with  mastication,  and  would  often  pass  unnoticed  by  the 
patient  himself.     It  is  probable,  too,  that  time,  and  the  constant  use 

'  Malgaigne,  from  Journ.  de  Med.,  par  Corvisart,  etc.,  torn.  x.  p.  195. 
"^  Smith,  New  York  Journ.  of  Med.  and  Surg.,  Jan.  1857. 
'  My  Report  on  Deformities  after  Frac,  Cases  2,  14,  15,  18. 


126  FEACTUEES    OF    THE    LOWEE    JAW. 

of  the  lower  jaw  in  mastication,  will  gradually  effect  a  marked  im- 
provement in  the  ability  to  bring  the  opposing  teeth  into  contact.  I 
think  I  have  observed  this  in  several  instances. 

Chelius  remarks  that  in  "double  or  oblique  fractures  it  is  very  dif- 
ficult to  keep  the  broken  ends  in  their  proper  place;  deformity  and 
displacement  of  the  natural  position  of  the  teeth  commonly  remain." 

in  the  second  esample  of  fracture  through  the  symphysis  mentioned 
by  me,  the  left  fragment  remained  slightly  elevated,  and  the  patient 
could  not  close  his  teeth  perfectly,  yet  he  could  close  them  sufficiently 
for  the  purposes  of  mastication.  It  is  probable,  however,  that  ordina- 
rily no  difficulty  will  be  experienced  in  accomplishing  a  perfect  cure, 
when  the  separation  has  taken  place  only  at  the  symphysis. 

In  fractures  of  the  condyles,  more  care  is  requisite  to  retain  the  frag- 
ments in  apposition,  and  sometimes  it  may  be  found  to  be  impossible. 
Richerand  mentions  the  case  of  a  man,  who,  having  been  three  months 
in  the  "Hopital  de  la  Charite,"  for  a  double  fracture  of  the  lower  jaw, 
one  fracture  being  near  the  middle,  and  the  other  near  the  right  con- 
dyle, left  before  the  cure  was  complete.  Seven  or  eight  months  after, 
he  called  uponBoyer,  who  extracted  from  a  fistula  in  the  meatus  audi- 
torius  externus,  a  bony  mass,  which  had  evidently  the  form  of  the 
condyle.-*  Bichat  mentions  a  similar  case  as  having  come  under  the 
observation  of  Desault  ;^  possibly  it  was  the  same  which  Boyer  saw. 
Eibes  says  that  a  Parisian  surgeon  treated  a  double  fracture  of  the  jaw 
in  a  gentleman,  one  fracture  being  through  the  body,  and  the  other 
through  the  neck  of  the  condyle;  and  in  spite  of  the  most  assiduous 
and  skilful  attention,  the  patient  recovered  with  a  lateral  distortion  of 
the  jaw,  occasioned  by  the  displacement  of  the  fragments.^  Ribes 
himself  had  to  treat  an  accident  of  a  similar  character,  and  notwith- 
standing all  his  care,  the  result  was  the  same  as  in  the  other  example 
just  cited.'' 

The  proximity  of  this  fracture  to  the  articulating  surface  may  occa- 
sion contraction  of  the  ligaments  about  the  joint:  and  a  degree  of 
embarrassment  to  the  motions  of  the  jaw  has  followed  in  the  expe- 
rience of  Desault  and  others,  even  when  the  cure  has  been  most  com- 
plete; but  this  has  usually  reniained  only  for  a  short  period. 

Sanson  asserts  that  when  the  coronoid  process  is  broken,  the  frac- 
ture never  unites;  but  that  mastication  is  performed  very  well,  the 
masseter  and  pterygoid  muscles  then  fulfilling  the  office  of  the  tem- 
poral.^ 

Treatment. — The  few  attempts  which  I  have  made  to  restore  a  com- 
pletely dislocated  tooth  to  its  socket,  or  to  retain  it  in  place  when  very 
much  loosened,  have  generally  resulted  in  its  removal  at  some  later 
day,  and  especially  where  the  fracture  has  been  near  the  angle,  and  a 
molar  has  been  disturbed.  I  believe  it  would  be  better  practice 
always  to  remove  the  molars  under  these  circumstances,  unless  they 

'  Boyer,  Lectures  on  Dis.  of  Bones,  p.  53,  Phila.  ed.,  1805. 

^  Desault,  Treatise  on  Fractures  and  Luxations,  Phila.  ed.,  1805,  p.  3. 

^  Malgaigne,  op.  cit.,  p.  402. 

■*  Ibid.,  p.  402. 

*  S.  Cooper's  First  Lines,  Amer.  ed.,  1844,  vol.  ii.  p.  311. 


FEAGTUEES    OF    THE    LOWEE    JAW.  127 

remain  attached  to  the  alveoli,  and  cannot  be  removed  TS'ithont  bring- 
ing them  away  also;  and  this,  whether  the  loosened  teeth  are  situated 
in  the  line  of  fracture  or  not.  It  is  seldom  that  they  can  be  made 
again  to  occupy  their  sockets  perfectly,  and  where  the  teeth  are  in  the 
line  of  the  fracture,  the  attempt  to  restore  them  to  place  will  sometimes 
prevent  the  proper  adjustment  of  the  fragments.  In  cases,  also,  in 
which  the  teeth  farther  forwards  are  completely  dislodged  at  the  seat 
of  fracture,  it  is  scarcely  worth  while  to  replace  them. 

As  to  those  teeth  whose  loosened  condition  is  due  only  to  a  splitting 
of  the  alveoli,  the  same  rule  will  not  always  apply.  Sometimes,  after 
a  careful  readjustment,  the  fragments  will  reunite,  and  the  teeth  re- 
main firm. 

If  the  bone  is  chipped  oft'  upon  the  outside,  through  or  near  the 
line  of  the  sockets,  the  teeth  may  not  be  always  much  disturbed,  and 
the  loss  of  the  fragments  may  be  of  less  consequence,  nor  have  I  gene- 
rally succeeded  in  saving  them ;  yet  if  they  remain  adherent  to  the  soft 
parts,  it  is  proper  to  make  the  attempt. 

The  expedients  to  which  surgeons  have  resorted  for  the  purpose  of 
retaining  in  place  the  fragments,  when  the  bone  is  broken  through  its 
body,  may  be  arranged  under  the  names  of  ligatures,  splints,  bandages, 
and  slings. 

The  ligature  has  been  applied  both  to  the  teeth  and  to  the  bone 
itself.  Thus,  in  an  oblique  fracture  near  the  angle,  where  the  frag- 
ments could  not  otherwise  be  prevented  from  falling  inwards,  Baudens 
passed  a  strong  ligature,  formed  of  thread,  around  the  fragments  and 
in  immediate  contact  with  them,  tying  the  ligature  over  the  teeth 
within  the  mouth.  iSTo  accident  followed,  and  on  the  twenty-third 
day,  when  he  removed  the  ligature,  the  bone  had  united  firmly  and 
smoothly.^ 

In  the  case  of  the  fracture  of  the  inferior  maxilla,  reported  by  Dr. 
Buck,  to  the  Xew  York  Pathological  Society,  and  already  referred  to, 
the  bone  "was  broken  between  the  two  incisor  teeth  of  the  left  side: 
the  part  of  the  bone  on  the  left  of  the  fracture  was  driven  in,  and 
interlocked  behind  the  end  of  the  right  portion,  so  as  to  be  separated 
by  a  fingers  breadth.  Finding  it  impossible  otherwise  to  reduce  the 
fracture.  Dr.  B.  dissected  off"  the  under  lip,  so  as  to  expose  the  fracture. 
He  found  that  the  right  anterior  portion  of  the  fractured  bone  ter- 
minated in  an  angular  projection  as  far  as  on  a  line  below  the  left 
angle  of  the  mouth.  The  lip  was  then  divided  to  the  chin,  and  the 
soft  parts  holding  the  fragments  together  incised.  A  chisel  was  then 
insinuated  behind  the  projecting  angle  of  the  bone,  while  it  was  being 
excised  by  the  metacarpal  saw.  When  the  bone  was  restored  to  its 
natural  position,  it  was  found  so  apt  to  become  displaced,  that  holes 
were  drilled  at  the  lower  angle  of  the  fracture,  and  adjustment  main- 
tained by  wiring  them  together,  the  wire  passing  out  through  the 
lower  angle  of  the  wound.  Sutures  and  adhesive  straps,  with  a  band- 
age, were  employed  to  maintain  the  adjustment  of  the  parts.  So  far 
the  patient  has  done  well,  being  supported  by  liquid  nourishment 

'  Malgaigne,  op.  cit.,p.  398. 


128  FEACTURES    OF    THE    LOWER    JAW. 

introduced  through  a  tube,  passed  througli  the  space  left  by  one  of 
the  incisors,  which,  on  account  of  its  looseness,  was  removed."^ 

In  May,  1858,  while  trephining  at  the  angle  of  the  jaw  for  the  purpose 
of  cutting  out  a  portion  of  the  dental  nerve  in  a  patient  suffering  from 
neuralgia,  I  accidentally  broke  the  jaw  in  two  at  the  point  at  which 
the  trephine  was  applied.  I  immediately  bored  a  hole  in  the  opposite 
extremities  of  the  two  fragments,  and  fastened  them  together  with  a 
silver  wire,  by  which  I  was  able  to  maintain  complete  apposition,  and 
in  three  weeks  the  union  was  accomplished,  the  wire  separating  and 
falling  out  of  itself.     No  splints  were  ever  used.^ 

With  these  exceptions,  so  far  as  I  am  aware,  the  ligature  has  been 
employed  as  a  means  of  retention  only  by  fastening  it  upon  the  teeth, 
either  upon  those  which  are  situated  on  the  opposite  sides  of  the 
fracture,  or  upon  others  a  little  more  remote,  or  upon  the  correspond- 
ing teeth  of  the  upper  jaw,  or  upon  the  teeth  on  the  opposite  sides  of 
the  same  jaw. 

Ordinarily  the  ligature,  composed  of  either  fine  gold,  platinum,  or 
silver  wire,  or  of  firm  silk  or  linen  threads — (Celsus  advised  the  use 
of  horsehair) — has  been  applied  to  the  two  teeth  on  the  opposite  sides 
of  the  fracture,  or  if  these  have  been  not  sufficiently  firm,  to  the  next 
teeth.  This  practice,  recommended  first  by  Hippocrates,  has  received 
the  occasional  sanction  of  Ryff',  Walner,  Chelius,  Lizars,  Erichsen, 
Miller,  B.  Cooper,  Skey,  and  others,  but  by  Boyer,  Gibson,  and  Mal- 
gaigne,  it  has  been  reprobated. 

Dr.  S.  G.  Ellis,  of  Gowanda,  N.  Y.,  as  we  have  already  seen,  has 
treated  a  fracture  occurring  through  the  symphysis,  in  an  adult,  by 
placing  the  mainspring  of  a  watch  within  the  dental  arcade,  and 
securing  it  in  place  with  silver  wire.  The  mouth  was  kept  closed  by 
bandages  carried  under  the  chin.  The  fragments  united  with  only  a 
slight  vertical  displacement.^ 

Dr.  George  Haywood,  of  Boston,  surgeon  to  the  Massachusetts 
General  Hospital,  says :  "  When  the  bone  is  not  comminuted  and  there 
are  teeth  on  each  side  of  the  fracture,  the  ends  of  the  bone  can  be 
kept  in  exact  apposition  by  passing  a  silver  wire  or  strong  thread 
around  these  teeth  and  tying  it  tightly.  In  several  cases  of  fracture 
of  the  jaw,  in  which  the  bone  was  broken  in  one  place  only,  I  have  in 
the  course  of  the  last  few  years,  adopted  this  practice  with  entire  suc- 
cess, and  without  the  aid  of  any  other  means.  It  will  be  found  very 
useful,  also,  as  an  auxiliary,  in  more  severe  cases,  in  which  it  may  be 
required  to  use  splints  and  bandages,  or  to  insert  a  piece  of  cork 
between  the  jaws,  as  recommended  by  Delpech.  It  requires  some 
mechanical  dexterity  to  apply  the  thread  neatly ;  but  in  large  cities 
we  can  avail  ourselves  of  the  skill  of  dentists  for  this  purpose."'*  I 
have  myself  in  two  or  three  instances  used  a  linen  thread  with 
excellent  results. 

Guillaume  de  Salicet  advises  to  secure,  with  a  silk  thread,  at  the 

'  New  York  Journ.  of  Med.,  &c.,  March,  1847,  p.  211. 

2  Buffalo  Med.  Journ.,  vol.  xiv.  p.  148. 

3  Trans.  Amer.  Med.  Assoc.     My  report  on  "Defor.,"  &c.  vol.  viii.  p.  383,  Case  14. 
*  Boston  Med.  &  Surg.  Journ.,  vol.  xix.  p.  133,  1838. 


FEACTUEES    OF    THE    LOWEE    JAW.  129 

same  moment  the  teeth  belonging  to  the  two  fragments,  and  the  cor- 
responding teeth  of  the  upper  jaw;^  while  the  dentist  Lemaire,  being 
applied  to  by  Dupuytren  to  secure  in  place  the  ununited  fragments  of 
a  broken  jaw,  fastened  the  two  left  canine  teeth  to  each  other  by  a 
wire  of  platinum,  as  had  been  already  suggested  by  Guillaume  de 
Salicet ;  to  these  he  added  two  other  modes  of  ligature  which  were 
altogether  original.  One  wire,  made  fast  to  the  last  molar  upon  one 
side,  traversed  the  mouth  and  was  secured  to  one  of  the  bicuspids 
upon  the  opposite  side ;  the  other  was  stretched  from  the  first  in- 
ferior bicuspid  on  the  right  to  the  first  superior  bicuspid  on  the  left. 
A  cure  was  accomplished  at  the  end  of  two  months,  but  one  of  the 
wires  had  nearly  bisected  the  tongue;  and  as  it  had  gradually  become 
imbedded,  the  flesh  had  closed  over  it  until  it  rested  like  a  seton 
through  the  middle  of  the  tongue  P 

None  of  these  various  methods  recommend  themselves  very  satis- 
factorily to  the  practical  surgeon  ;  for  besides  that  they  are  all  of  them, 
in  a  large  majority  of  cases,  wholly  unnecessary,  and  in  other  cases, 
owing  to  the  absence  of  the  teeth,  or  to  their  loosened  or  decayed 
condition,  or  to  the  closeness  with  which  they  are  set  against  each 
other,  absolutely  impossible,  it  must  be  seen,  also,  that  they  will 
generally  prove  feeble  and  inefficient.  The  wires  act  only  upon  the 
upper  extremity  of  the  line  of  fracture,  leaving  its  lower  portions 
liable  to  be  disturbed  by  trivial  causes;  they  tend  gradually  to  loosen 
even  the  firm  teeth  which  they  embrace,  and  not  unfrequently,  after 
having  been  made  fast  with  much  labor,  they  soon  become  disarranged 
or  break.  They  require,  therefore,  always  the  additional  protection 
afforded  by  bandages.  Alone  they  are  insufficient,  and  if  properly 
constructed  bandages  or  slings  are  employed,  they  are  not  needed. 
Sometimes,  moreover,  they  are  actually  mischievous,  as  when  they 
loosen  a  sound  tooth  or  press  upon  and  inflame  the  gums.  A,  Bdrard 
passed  a  silver  wire  twice  around  the  necks  of  two  adjoining  teeth  on 
the  opposite  sides  of  a  fracture.  It  retained  the  fragments  perfectly 
in  apposition  during  several  days;  but  soon  the  gums  swelled  and 
became  painful ;  the  teeth  loosened,  and  it  was  found  necessary  to 
remove  the  wire.  Chassaignac  sought  to  avoid  these  evils  by  placing 
the  wire  upon  the  middle  of  the  crown,  free  from  the  gums,  and  by 
including  four  teeth  instead  of  two.  A  waxed  linen  thread  was  made 
fast  in  this  manner,  in  a  case  of  simple  fracture,  on  the  seventh  day. 
On  the  following  morning  the  thread  was  found  broken.  He  applied 
then  a  silk  ligature  in  the  same  manner.  On  about  the  third  day  this 
also  was  disarranged  ;  the  ligatures  were  now  discontinued  until  the 
eighteenth  day,  when  he  renewed  the  experiment  with  a  piece  of  gold 
wire.  Fourteen  days  after  this  the  ligature  remained  firm,  but  the 
gums  were  red  and  bleeding.  The  patient  not  having  again  returned 
to  Chassaignac,  the  result  is  not  known.^ 

As  to  the  method  suggested  by  Guillaume  de  Salicet,  it  presents  no 
advantages  to  compensate  for  its  inconveniences;  while  that  actually 

'  Malgaigne,  op.  cit.,  p.  392. 

^  ,Iour.  Uiiiver.  des  Sci.  Med.,  torn.  xix.  p.  77. 

3  Lond.  Med.  &  Phys.  Joum.,  Nov.  1822,  p.  401. 


130  FEACTURES    OF    THE    LOWER   JAW. 

practised  by  the  dentist  Lemaire,  successful,  indeed,  threatened  to  sub- 
stitute a  loss  of  the  tongue  for  an  ununited  fracture  of  the  jaw. 

Splints  have  been  employed  in  various  ways.  First,  simple  inter- 
dental splints,  laid  along  the  crowns  of  the  teeth  and  only  sufficiently 
grooved  to  be  easily  retained  in  place ;  Second,  clasps,  which  are  ap- 
plied over  the  crowns  and  sides  of  the  teeth,  operating  chiefly  by  their 
lateral  pressure;  Third,  splints  applied  to  the  outer  and  inferior  margin 
of  the  jaw;  Fourth,  interdental  splints  or  clasps,  combined  with  out- 
side splints. 

Interdental  splints  have  been  recommended  by  many  surgeons  from 
an  early  day,  and  they  continue  to  be  employed  occasionally  up  to 
this  moment. 

Boyer  advises  the  use  of  cork  splints  placed  one  on  each  side  be- 
tween the  upper  and  lower  jaws,  in  a  few  exceptional  cases.  Miller 
recommends  the  same  in  all  cases,  the  "two  edges  of  cork  sloping 
gently  backwards,  with  their  upper  and  under  surfaces  grooved  for 
the  reception  of  the  upper  and  lower  teeth."  Fergusson  also  has 
usually  adopted  the  same  practice.  Muys  and  Bertrandi  employed 
ivory  wedges.^ 

On  the  other  hand  they  are  rejected  entirely  by  Syme,  Chelius,  Skey, 
Erichsen,  and  Gribson. 

The  objections  which  have  been  stated  to  their  use  are :  that  they 
are  unsteady  and  become  easily  loosened  and  disarranged ;  that  they 
occasionally  press  painfully  upon  the  inside  of  the  cheeks ;  that  they 
accumulate  about  themselves  an  offensive  sordes,  and  finally  that  they 
are  unnecessary,  since  experience  has  proven,  says  Gibson,  that  "there 
is  always  sufficient  space  between  the  teeth  to  enable  the  patient  to 
imbibe  broth  or  any  other  thin  fluid  placed  between  the  teeth." 

It  is  not  strictly  true,  however,  that  in  all  cases  there  will  be  found 
sufficient  space  between  the  teeth,  when  the  mouth  is  closed,  for  the 
imbibition  of  nutrient  fluids.  I  have  myself  seen  exceptions,  and  in 
such  a  case  the  patient,  if  the  mouth  were  closed  in  the  usual  way, 
would  have  to  be  fed  through  a  tube  conveyed  along  the  nostrils  into 
the  stomach,  as  suggested  by  both  Samuel  and  Bransby  Cooper  in 
certain  bad  compound  fractures,  or  through  an  opening  made  by  the 
extraction  of  one  of  the  front  teeth ;  neither  of  which  methods  ought 
to  be  preferred  to  the  interdental  splints;  but  then  the  separation  of 
the  front  teeth  for  the  purpose  of  receiving  food,  is  by  no  means  the 
only  object  to  be  gained  by  their  use,  nor  indeed  the  principal  object. 
Their  great  purpose  is  to  act  as  splints  whenever  the  absence  of  teeth 
either  in  the  upper  or  lower  jaw  renders  the  two  corresponding  arcades 
unequal  and  irregular  and  prevents  our  making  use  of  the  upper  jaw 
as  a  kind  of  internal  splint  for  the  lower  jaw. 

It  is  with  a  view  to  the  accomplishment  of  this  important  end  that 
they  are  often  valuable,  and  ought  sometimes  to  be  considered  as  in- 
dispensable. I  believe,  also,  that  many  of  the  inconveniences  which 
have  been  found  to  attend  the  use  of  cork  or  wood,  are  obviated  by 
the  substitution  of  gutta  percha  in  the  manner  which  I  have  already 
recommended  in  my  report  to  the  American  Medical  Association, 

'  Lond.  Med.-Chir.  Rev.,  vol.  xx.  p.  470. 


FRACTURES    OF    THE    LOWER    JAW.  131 

made  in  the  year  1855.  I  have  employed  this  method  several  times 
myself,  and  my  suggestions  have  been  followed  by  Stephen  Smith,  of 
the  Beilevue  Hospital,  New  York,  who,  after  having  used  the  gutta 
percha  in  four  cases,  affirms  that  nothing  can  surpass  it  in  efficiency. 

The  mode  of  preparing  gutta  percha,  and  of  adapting  it  between 
the  teeth,  is  as  follows:  Dip  a  couple  of  pieces  of  the  gum,  of  a 
proper  size,  into  boiling  water,  and  when  they  are  sufficiently  soft- 
ened, mould  them  into  wedge-shaped  blocks,  and,  having  wrapped 
each  block  with  a  piece  of  cotton  cloth,  carry  them  to  their  appro- 
priate places  between  the  back  teeth;  immediately  press  up  each  hori- 
zontal ramus  of  the  jaw  until  the  mouth  is  sufficiently  closed,  and  the 
line  of  the  inferior  margin  is  straight;  in  this  position  retain  the  frag- 
ments a  few  minutes,  until  the  gum  has  sufficiently  hardened.  Mean- 
time, it  w^ill  be  practicable,  generally,  to  introduce  the  fingers  into  the 
mouth,  and  to  press  the  gutta  percha  laterally  on  each  side  towards 
the  teeth,  and  thus  to  make  its  position  more  secure.  When  it  is 
sufficiently  hardened,  remove  the  splints  for  the  purpose  of  determining 
more  precisely  that  they  are  properly  shaped  and  fitted. 

The  superiority  of  this  splint  is  now  at  once  perceived.  If  properly 
made,  it  is  smooth  upon  its  surface,  and  not,  therefore,  so  liable  to 
irritate  the  mouth  as  wood  or  cork,  and  it  is  so  moulded  to  the  teeth 
that  it  wmII  never  become  displaced. 

The  clasp,  applied  over  the  crowns  and  sides  of  the  teeth  is  not  in- 
tended to  act  as  an  interdental  splint;  but  by  its  lateral  pressure  it  is 
expected  to  hold  the  fragments  in  apposition  upon  nearly  the  same 
principle  with  the  ligature. 

Mutter,  of  Philadelphia,  employs  for  this  purpose  a  plate  of  silver 
folded  snugly  over  the  tops  and  sides  of  two  or  more  teeth  adjacent  to 
the  fracture,  which  apparatus  he  calls  a  "  clamp.'" 

Nicole,  of  Nuremburg,  employed  for  the  same  purpose  Fig.  25. 
a  couple  of  steel  plates  fitted  accurately  along  the  an- 
terior and  posterior  dental  curvatures,  secured  in  place 
by  a  steel  clasp,  the  clasp  being  furnished  -with  a  thumb- 
screw, in  order  the  more  effectually  to  accomplish  the 
lateral  pressure.  ,,..,,, ,      ,„^„ 

ATT  T  iii'T  fTv-r-11  1-  Mutters     clamp 

Malgaigne  has  extended  the  idea  of  JNicole,  by  substi-  for  fractured  jaw. 
tuting  for  the  two  steel  plates,  a  single  plate  composed 
of  flexible  and  ductile  iron,  which  is  fitted  accurately  to  all  the  irregu- 
larities of  the  posterior  dental  arch.  From  the  two  extremities  of  this 
plate,  and  from  two  other  intermediate  points,  four  small  steel  shafts 
arise  perpendicularly,  cross  the  crowns  of  the  teeth  at  right  angles, 
and  then  fall  down  again  perpendicularly  upon  the  anterior  dental 
arcade.  Each  steel  shaft  being  furnished  with  a  thumb-screw,  the 
iron  plate  can  now  be  made  to  bear  against  the  teeth  so  as  to  form  a 
posterior  dental  splint.  The  teeth  are  also  protected  in  front  against 
the  direct  action  of  the  thumb-screw  by  the  interposition  of  a  leaden 
plate. 

I  am  not  aware  that  either  of  these  modes  has  ever  been  practically 
tested ;  and  I  confess  that  I  can  see  many  disadvantages  and  incon- 


Trans.  Am.  Med.  Assoc,  vol.  viii.  p.  391. 


132  PEACTUEES    OF    THE    LOWEE    JAW. 

veniences  whicli  would  be  likely  to  arise  from  their  use.  With  the 
exception  of  Mutter's  "  clamp,"  they  are  all  complex  and  must  be 
liable  to  disarrangement;  while  thumbscrews  in  the  mouth  cannot 
but  inflict  serious  injury  by  their  pressure  and  friction  against  the 
mucous  membrane. 

Gutta  percha  employed  in  the  manner  which  I  have  recommended, 
is  capable  of  giving  no  inconsiderable  degree  of  lateral  support  to  the 
teeth,  and  I  suspect  quite  as  much  as  the  comfort  or  interest  of  the 
patient  will  permit,  and  without  many  of  the  inconveniences  of  the 
other  modes,  while  it  possesses  the  additional  advantage  of  serving 
also,  where  this  is  needed,  as  an  efficient  interdental  splint. 

External  splints,  applied  along  the  base  or  outside  of  the  jaw,  were 
first  recommended  by  Pard,  who  used,  for  this  purpose,  leather;  and 
they  have  been  employed  in  some  form,  occasionally,  by  most  surgeons. 
Generally  they  have  been  composed  of  flexible  materials,  such  as 
wetted  pasteboard,  first  recommended  by  Heister,  felt,  linen  saturated 
with  the  whites  of  eggs,  paste,  dextrine  or  starch  ;  plaster  of  Paris  has 
also  been  used:  and  they  have  been  retained  in  place  by  either  band- 
ages or  the  sling.  I  have  myself  used  for  this  purpose,  gutta  percha, 
but  I  shall  speak  of  it  as  one  form  of  the  sling  dressing. 

Undoubtedly  useful,  and  even  necessary  in  some  cases,  especially 
where  there  exists  a  great  tendency  to  a  vertical  displacement,  they 
will  be  found,  also,  in  many  cases,  to  render  no  essential  service,  and 
may  properly  enough  be  dispensed  with. 

W.hatever  objections  hold  to  the  use  of  metallic  clasps,  must  hold 
equally  to  the  use  of  those  forms  of  apparatus  in  which  it  is  attempted 
to  secure  the  fragments  by  means  of  a  combination  of  these  clasps  with 
outside  splints,  and  in  which  it  is  proposed  to  dispense  with  all  band- 
ages or  slings,  the  mouth  being  permitted  to  open  and  close  freely 
during  the  whole  treatment.  They  are  liable,  moreover,  to  additional 
objections,  which  will  be  readily  suggested  by  an  explanation  of  their 
mode  of  construction. 

Chopart  and  Desault  originated  this  idea  as  early  as  1780,  for  frac- 
tures occurring  upon  both  sides;  in  which  cases  they  advised  "band- 
ages composed  of  crotchets  of  iron  or  of  steel,  placed  over  the  teeth, 
upon  the  alveolar  margin,  covered  with  cork  or  with  plates  of  lead, 
and  fastened  by  thumb-screws  to  a  plate  of  sheet  iron,  or  to  some 
other  material  under  the  jaw." 

The  apparatus  invented  by  Eutenick,  a  German  surgeon,  in  1799, 
and  improved  by  Kluge,  is  thus  described  by  Dr.  Chester :  "  It  con- 
sists, 1st,  of  small  silver  grooves,  varying  in  size  according  as  they 
are  to  be  placed  on  the  incisors  or  molars,  and  long  enough  to  extend 
over  the  crowns  of  four  teeth ;  2d,  of  a  small  piece  of  board,  adapted 
to  the  lower  surface  of  the  jaw,  and  in  shape  resembling  a  horseshoe, 
having  at  its  two  horns,  two  holes  on  each  side ;  3d,  of  steel  hooks  of 
various  sizes,  each  having  at  one  extremity  an  arch  for  the  reception 
of  the  lower  lip,  and  another  smaller  for  securing  it  over  the  silver 
channels  on  the  teeth,  and  at  the  other  end  a  screw  to  pass  through  the 
horseshoe  splint,  and  to  be  secured  to  it  by  a  nut  and  a  horizontal 
branch  at  its  lower  surface ;  4th,  of  a  cap  or  silk  nightcap  to  remain 


FEACTURES    OF    THE    LOWER    JAW.  133 

on  the  head ;  and  5th,  of  a  compress  corresponding  in  shape  and  size 
with  the  splint.  The  net  or  cap  having  been  placed  on  the  head  and 
the  two  straps  fastened  to  it  on  each  side,  one  immediately  in  front  of 
the  ear  and  the  other  about  three  inches  farther  back,  which  are  to 
retain  the  splint  in  its  position  by  passing  through  the  two  holes  in 
each  horn  ;  a  silver  channel  is  placed  on  the  four  teeth  nearest  to  the 
fracture,  on  this  the  small  arch  of  the  hook  is  placed,  and  the  screw 
end  having  been  passed  through  a  hole  in  the  splint,  is  screwed  firmly 
to  it  by  the  nut,  after  a  compress  has  been  placed  between  the  splint 
and  the  integuments  below  the  jaw. 

"  If  there  is  a  double  fracture,  two  channels  and  two  hooks  nrjust  of 
course  be  used."' 

Bush  invented  a  similar  apparatus  in  1822,^  and  Houzelot  in  1826; 
since  which  the  apparatus  has  been  variously  modified  by  Jousset, 
Lonsdale,  Malgaigne,  and  perhaps  others. 

Lonsdale  says  he  has  employed  his  instrument  in  numerous  cases 
and  with  complete  success.^  Eutenick  succeeded  wnth  his  apparatus 
in  a  case  where  the  displacement  persisted  in  spite  of  all  other  means.^ 
Jousset  was  also  successful  in  two  cases.* 

But  others  have  not  been  equally  fortunate ;  or  if  they  have  suc- 
ceeded in  holding  the  fragments  in  apposition,  and  in  securing  a  bony 
union,  other  serious  accidents  have  followed. 

In  the  first  case  mentioned  by  Houzelot,  the  instrument  was  kept 
on  thirteen  days,  after  which  an  attack  of  epilepsy  deranged  every- 
thing, and  the  patient  was  transferred  to  Bicetre.  The  second  patient 
complained  immediately  of  an  intense  pain  under  the  chin  and  a  pro- 
fuse salivation  followed.  These  symptoms  were  subdued  by  the  sixth 
day,  but,  for  some  reason,  the  apparatus  was  finally  removed  on  the 
tenth  day.  The  fragments  hereafter  showed  no  tendency  to  derange- 
ment. Seven  days  after  its  removal  an  abscess,  which  had  formed 
under  the  chin,  was  opened.  In  the  third  case  the  apparatus  was  left 
in  place  thirty  days,  and  an  abscess  formed  also  under  the  chin.  Neu- 
court  applied  it  in  a  double  fracture  where  the  central  fragment  was 
much  displaced.  The  apposition  was  well  preserved,  but  he  w'as 
obliged  to  remove  it  on  the  seventeenth  day  on  account  of  a  phlegmon 
which  was  forming  under  the  chin.  The  patient  to  whom  Bush  ap- 
plied his  apparatus,  would  wear  it  but  a  few  days.  Malgaigne  had 
the  same  experience  with  Bush's  apparatus. 

In  addition  to  the  pain  and  inflammation,  followed  by  submaxillary 
abscesses,  which  have  been  such  frequent  results  of  its  use,  Mal- 
gaigne has  noticed  that  it  is  exceedingly  inclined  to  slide  forwards 
and  become  displaced. 

In  short,  notwithstanding  the  unqualified  testimony  of  Lonsdale  in 
favor  of  this  method  of  treatment,  especially  in  fractures  at  the  sym- 
physis, and  in  fractures  through  any  portion  of  the  shaft  anterior  to 
the  masseter  muscle,  it  is,  in  my  judgment,  sufficiently  plain  that  it  is 

'  London  Med.-Chir.  Rev.,  voL  xs.  p.  471,  from  Monthly  Archives  of  the  Medical 
Sciences,  1S34.  ^  Malgaigne,  op.  cit.,  p.  395. 

^  Lonsdale  :  Practical  Treatise  on  Fractures  ;  London,  183S,  p.  234. 
*  Malgaigne,  op.  cit.,  p.  396.  ^  Ibid.,  p.  396. 


134 


FEACTURES    OF   THE    LOWER    JAW. 


Fig.  26. 


applicable  to  only  a  very  limited  number  of  cases,  and  I  am  not  cer- 
tain but  that  it  would  be  better  to  reject  it  altogether;  and  I  should 
scarcely  have  thought  it  worth  while  to  notice  these  modes  of  treat- 
ment at  all  were  it  not  for  the  respectability  of  the  gentlemen  who 
have  given  them  their  countenance,  and  perhaps  to  show  how  fruitful 
and  exhaustless  in  resources  is  the  genius  of  our  profession. 

The  treatment  of  fractures  of  the  inferior  maxilla  by  a  single-headed 
bandage  or  roller,  numbers  among  its  distinguished  advocates  the  names 
of  Gibson  and  Barton;  indeed,  I  think  the  practice  is  at  the  present  time 
peculiar  to  a  few  American  surgeons.  Gibson  gives  the  following  direc- 
tions for  applying  his  roller :  "  A  cotton  or  linen  compress,  of  moderate 
thickness,  reaching  from  the  angle  of  the  jaw  nearly  to  the  chin,  is 

placed  beneath  and  held  by  an  assistant, 
while  the  surgeon  takes  a  roller,  four  or 
five  yards  long,  an  inch  and  a-half  wide, 
and  passes  it  by  several  successive  turns 
under  the  jaw,  up  along  the  sideS  of  the 
face  and  over  the  head;  now  changing 
the  course  of  the  bandage,  he  causes  it 
to  pass  off  at  a  right  angle  from  the  per- 
pendicular cast,  and  to  encircle  the  tem- 
ple, occiput  and  forehead,  horizontally, 
by  several  turns;  finally,  to  render  the 
whole  more  secure,  several  additional 
horizontal  turns  are  made  around  the 
back  of  the  neck,  under  the  ear,  along 
the  base  of  the  jaw,  over  the  point  of 
the  chin.  To  prevent  the  roller  from 
slipping  or  changing  its  position,  a  short 
piece  may  be  secured  by  a  pin  to  the  horizontal  turn  that  encircles 
the  forehead,  and  passed  backwards  along  the  centre  of  the  head  as 
far  as  the  neck,  where  it  must  be  tacked  to  the  lower  horizontal  turn 
— taking  care  to  fix  one  or  more  pins  at  avery  point  at  which  the 
roller  has  crossed." 

Barton  employs,  also,  a  compress,  and  a  roller  five  yards  long ;  the 
application  of  which  is  thus  described  by  Sargent:  Place  the  initial  ex- 
•p.    27  tremity  of  the  roller  upon  the  occiput,  just 

below  its  protuberance,  and  conduct  the 
cylinder  obliquely  over  the  centre  of  the  left 
parietal  bone  to  the  top  of  the  head;  thence 
descend  across  the  right  temple  and  the  zy- 
gomatic arch,  and  pass  beneath  the  chin  to 
the  left  side  of  the  face ;  mount  over  the  left 
zygoma  and  temple  to  the  summit  of  the 
cranium,  and  regain  the  starting-point  at  the 
occiput  by  traversing  obliquely  the  right 
parietal  bone;  next  wind  around  the  base  of 
the  lower  jaw  on  the  left  side  to  the  chin, 
and  thence  return  to  the  occiput  along  the 
Barton's  bandage  for  a  fractured  jaw.  ^ight  sidc  of  the  maxilla;  repeat  the  same 


Gibson's  bandage  for  a  fractured  jaw. 


FEACTUEES    OF    THE    LOWEE   JAW. 


135 


course,  step  by  step,  until  the  roller  is  spent,  and  then  confine  its 
terminal  end. 

These  bandages  possess  the  advantages  of  being  easily  obtained,  of 
simplicity  and  facility  of  application,  and  in  general,  we  may  add,  of 
complete  adaptation  to  the  ends  proposed.  The  only  objections  to 
their  use  which  I  have  ever  noticed,  are  occasional  disarrangements, 
and  the  tendency,  as  in  all  other  continuous  rollers,  to  draw  the  frag- 
ments to  one  side  or  the  other,  according  as  the  successive  turns  of 
the  bandage  are  carried  to  the  right  or  left.  There  is  one  other  ob- 
jection, having  reference  to  the  occasional  inadequacy  of  this  dressing 
to  prevent  an  overlapping  of  the  fragments,  to  which  objection  also 
the  sling,  as  usually  constructed,  is  equally  obnoxious,  and  of  which 
I  shall  speak  presently. 

Finally,  it  is  to  the  sling,  in  some  of  its  various  forms,  that  surgeons 
have  generally  given  the  preference.     The  sling  is  known,  also,  b}' 
the  name  of  the  four-headed  or  the 
four-tailed  roller  or  bandage. 

B.  Bell,  Boyer,  Skey,  S,  Cooper, 
B.  Cooper,  Syme,  Fergusson,  Mayor, 
Lizars,  and  Chelius,  employ  the  sling 
usually;  and  the  favorite  mode  is  to 
use  for  this  purpose  a  piece  of  muslin 
cloth  about  one  yard  long  and  four 
inches  wide,  torn  down  from  its  two 
extremities  to  within  about  three  or 
four  inches  of  the  centre.  Others 
have  used  leather,  gutta  percha,  ad- 
hesive straps,  gum-elastic,  etc. 

Where  the  muslin  is  used,  it  is 
quite  customary  to  lay  against  the 
skin  a  piece  of  pasteboard,  wetted, 
and  moulded  to  the  chin,  or  simply  a 
soft  compress;  and  some  choose  to 
open  the  centre  of  the  bandage  suffi- 
ciently to  receive  the  chin.  The  mid- 
dle of  this  bandage  being  laid  upon  the  chin,  the  two  ends  correspond- 
ing to  the  upper  margin  of  the  roller  are  now  carried  across  the  front 
of  the  chin,  behind  the  nape  of  the  neck,  and  made 
fast;  while  the  two  lower  heads  are  brought  di- 
rectly upwards  from  under  the  sides  of  the  chin, 
along  the  sides  of  the  face,  in  front  of  the  ears,  and 
made  fast  upon  the  top  of  the  head.  The  dressing 
is  completed  by  a  short  counter-band  extending 
across  the  top  of  the  head  from  one  bandage  to  the 
other ;  or  the  several  bands  may  be  made  fast  to  a 
nightcap,  in  which  case  the  counter-band  will  be 
unnecessary. 

It  only  remains  for  me  to  describe  my  own  method  of  dressing  these 
fractures  with  the  sling. 

Having  frequently  noticed  the  tendency  of  the  sling,  as  ordinarily 


Four-tailed  bandage  or  sling,  for  the  lower  jaw. 


Pasteboard  compress. 


136 


FEACTUEES    OF    THE    LOWEE    JAW. 


constructed,  and  of  Gibson's  roller,  to  carry  the  anterior  fragment 
backwards,  especially  in  double  fractures  where  the  body  of  the  bone 
is  broken  upon  both  sides,  I  devised,  some  years  since,  an  apparatus 
intended  to  obviate  this  objection,  and  which  I  have  used  now  several 
times  with  complete  success. 

It  is  composed  of  a  firm  leather  strap,  called  maxillary,  which,  pass- 
ing perpendicularly  upwards  from  under  the  chin,  is  made  to  buckle 

upon  the  top  of  the  head,  at  a  point  near 
the  situation  of  the  anterior  fontanelle. 
This  strap  is  supported  by  two  counter- 
straps,  called,  respectively,  occipital  and 
frontal,  made  of  strong  linen  webbing. 
One  of  these,  the  occipital,  is  attached  to 
the  posterior  margin  of  the  maxillary 
strap  about  half  an  inch  above  the  ear, 
and  being  carried  around  behind  and 
under  the  occiput,  it  is  finally  buckled  to 
the  maxillary  strap  upon  the  opposite 
side,  and  at  a  point  exactly  corresponding 
to  its  origin.  The  frontal  stay  simply 
antagonizes  the  occipital;  and  having  its 
origin  and  termination  at  the  anterior 
margins  of  the  maxillary  strap,  it  is 
buckled  horizontally  across  the  forehead, 
and  just  above  the  eyebrows. 

The  maxillary  strap  is  narrow  under 
the  chin  to  avoid  pressure  upon  the  front  of  the  neck,  but  immediately 
becomes  wider  so  as  to  cover  the  sides  of  the  inferior  maxilla  and  face, 
after  which  it  gradually  diminishes  to  accommodate  the  buckle  upon 
the  top  of  the  head.  The  anterior  margin  of  this  band,  at  the  point 
corresponding  to  the  symphysis  menti,  and  for  about  two  inches  on 
each  side,  is  supplied  with  thread  holes,  for  the  purpose  of  attaching 
a  piece  of  linen  which,  when  the  apparatus  is  in  place,  shall  cross  in 
front  of  the  chin,  and  prevent  the  maxillary  strap  from  sliding  back- 
wards against  the  front  of  the  neck. 

The  advantage  of  this  dressing  over  any  which  I  have  yet  seen, 
consists  in  its  capability  to  lift  the  anterior  fragment  almost  vertically, 
and  at  the  same  time  it  is  in  no  danger  of  falling  forwards  and  down- 
wards upon  the  forehead.  If,  as  in  the  case  of  most  other  dressings, 
the  occipital  stay  had  its  attachment  opposite  to  the  chin,  its  effect 
would  be  to  draw  the  central  fragment  backwards.  By  using  a  firm 
piece  of  leather,  as  a  maxillary  band,  and  attaching  the  occipital  stay 
above  the  ears,  this  diflS.culty  is  completely  avoided. 

Having  removed  such  teeth  as  are  much  loosened  at  the  point  of 
fracture,  and  replaced  those  which  are  loosened  at  other  points,  unless 
it  be  far  back  in  the  mouth,  and  adjusted  the  fragments  accurately, 
the  lower  jaw  is  to  be  closed  completely  upon  the  upper,  and  the 
apparatus  snugly  applied.  It  is  not  necessary  in  most  cases,  to  buckle 
the  straps  with  great  firmness,  since  experience  has  shown  that  a 
suf&cient  degree  of  immobility  is  obtained  when  the  apparatus  is  only 


The  author's  apparatus. 


J 


FRACTURES    OF    THE    LOWER    JAW.  137 

moderately  tight.  In  this  matter  I  am  sustained  also  bj  the  opinion 
of  Mr.  Fergusson. 

If  the  integuments  are  bruised  and  tender,  a  compress  made  of  two 
or  more  thicknesses  of  patent  lint  should  be  placed  underneath  the  chin, 
between  it  and  the  leather. 

If  the  inability  to  introduce  nourishment  between  the  teeth  when  the 
mouth  is  closed,  or  the  irregularity  of  the  dental  arcade  renders  the 
use  of  interdental  splints  necessary,  gutta  percha,  as  I  have  already 
explained,  ought  to  be  preferred  to  any  other  material. 

The  patient  must  be  forbidden  to  talk,  or  laugh,  and  when  he  lies 
down  his  head  should  rest  upon  its  back,  for  whatever  mode  of  dress- 
ing is  employed,  and  however  carefully  it  is  applied,  it  will  be  found 
that  a  slight  motion  and  displacement  will  occur  whenever  the  \veight 
of  the  head  rests  upon  the  side  of  the  face. 

Occasionally,  indeed,  as  often  as  every  two  or  three  days,  the  appa- 
ratus may  be  loosened  or  removed,  only  taking  care  generally  not  to 
disturb  the  interdental  splints,  when  they  are  used,  and  to  support  the 
jaw  with  the  hand,  during  its  removal ;  and,  at  the  same  time,  the  face 
may  be  sponged  oft'  with  warm  water  and  castile  soap.  It  should  not 
be  left  off  entirely,  however,  in  less  than  three  or  four  weeks,  even 
where  the  fracture  is  most  simple,  nor  ought  the  patient  to  be  allowed 
to  eat  meat  in  less  than  four  or  five  weeks. 

To  cleanse  the  mouth  and  prevent  offensive  accumulations,  it  should 
be  washed  several  times  a  day  with  a  solution  of  tincture  of  myrrh, 
prepared  by  adding  one  drachm  to  about  four  ounces  of  water. 

The  same  apparatus,  and  without  any  essential  modification,  is  ap- 
plicable to  fractures  of  the  symphysis  and  of  the  angle  of  the  inferior 
maxilla,  as  well  as  to  fractures  of  the  body  of  the  bone. 

Instead  of  the  leather,  I  have  in  a  few  instances,  especially  of  com- 
pound fractures,  where  it  became  necessary  to  allow  the  pus  to  dis- 
charge externally,  used  a  sling  or  a  splint  composed  of  gutta  percha, 
suspended  by  bands  carried  over  the  top  of  the  head.  The  piece 
from  which  this  splint  is  made  should  be  two  or  three  lines  in  thick- 
ness, covered  with  cloth,  and  padded  under  the  chin.  It  will  be  found 
convenient  to  cover  it  with  cloth  before  immersing  it  in  the  hot  water. 
The  water  should  be  nearly  at  a  boiling  temperature,  so  that  the  splint 
may  become  perfectly  pliable;  and  it  should  be  laid  upon  the  face 
and  allowed  to  mould  itself  while  the  patient  lies  upon  his  back. 

Having  thus  fitted  it  accurately  to  the  face,  it  may  be  removed  and 
openings  made  at  points  corresponding  with  the  wounds  upon  the 
skin,  before  it  is  reapplied. 

In  fractures  of  either  condyle,  unaccompanied  with  displacement, 
the  simple  leather  or  muslin  sling  will  sometimes  accomplish  a  perfect 
and  speedy  cure,  as  the  two  cases  reported  by  Desault  will  sufficiently 
demonstrate.  But  if  the  fragments  have  become  separated,  the  re- 
placement is  difficult,  and  the  retention  uncertain. 

Eibes  was  the  first  to  suggest  and  to  practice  the  only  rational 
method  of  reduction  in  these  cases.  Having  seen  two  examples  which 
had  resulted  in  deformity  under  the  usual  treatment,  which  consisted 
in  simply  pressing  forwards  the  angle  of  the  jaw,  it  occurred  to  him 


138  FRACTUEES    OF    THE    HYOID    BONE. 

that  while  the  upper  or  condyloidean  fragment  was  not  acted  npon  at 
the  same  moment  by  pressure  from  the  opposite  direction,  a  reduction 
must  be  impossible.  The  case  of  a  cannonier  whose  jaw  was  broken 
through  the  neck  of  the  condyle  on  the  right  side,  and  through  its 
body  on  the  left,  afforded  him  an  opportunity  to  determine  the  practi- 
cability of  a  method  of  which  he  had  as  yet  only  conceived  the  idea. 
Malgaigne  thus  describes  his  procedure :  "  With  the  left  hand  seize  the 
anterior  portion  of  the  jaw,  for  the  purpose  of  drawing  it  horizontally 
forwards,  while  you  carry  the  index  finger  of  the  right  hand  to  the 
lateral  and  superior  part  of  the  pharynx.  You  will  meet  at  first  the 
projection  formed  by  the  styloid  process,  but  moving  your  finger  for- 
wards you  will  find  soon  the  posterior  border  of  the  ramus  of  the  jaw ; 
and  following  this  border  from  below  upwards,  you  will  arrive  at  the 
inner  side  of  the  condyle,  which  you  will  push  outwards  in  such  a 
manner  as  to  engage  it  upon  the  other  fragment.  This  manoeuvre 
cannot  be  made  without  causing  nausea,  as  the  finger  always  does 
when  carried  into  the  posterior  part  of  the  pharynx ;  but  this  is  a 
slight  inconvenience.  The  reduction  obtained,  bear  the  jaw  upwards 
and  backwards  in  order  to  press  and  fix  the  condyle  between  it  and 
the  glenoid  cavity,  then  fasten  it  in  place  with  the  sling,"  The  frag- 
ments were  thus  easily  brought  into  apposition  in  the  case  reported 
by  Ribes,  and  the  patient  was  cured  without  any  deformity. 

In  addition  to  these  means,  the  angle  of  the  jaw  ought  to  be  pressed 
permanently  forwards  by  means  of  a  compress  placed  between  it  and 
the  mastoid  process,  and  held  in  place  by  a  suitable  bandage. 

If  the  coronoid  process  be  alone  broken,  it  is  sufl&cient  to  close  the 
mouth  with  any  form  of  sling  or  bandage  which  may  be  most  con- 
venient. 


CHAPTER    XIII. 

FRACTURES  OF  THE  HYOID  BONE. 

M.  Oefila  has  reported  the  case  of  a  man,  aged  sixty-two  years,  who 
had  been  hanged,  and  whose  os  hyoides  was  broken  through  its  body  on 
its  right  side.'  M.  Cazauvieilh  has  also  seen  a  fracture  of  this  bone  in 
two  persons  who  had  been  hanged :  in  one  of  which  the  fracture  was 
probably  in  the  body  of  the  bone,  and  in  the  other  through  o'ne  of  its 
cornua.^ 

Lalesque  published  in  the  Journal  Hebdomadaire^  for  March,  1833,  a 
case  which  occurred  in  a  marine,  sixty-seven  years  old,  "  who,  in  a 

'  Traite  de  Med.  legale,  troisieme  ed.,  torn.  ii.  p.  423. 
^  Cazauvieilh,  du  Suicide,  etc.,  p.  221. 


FRACTURES    OF    THE    HYOID    BONE.  139 

quarrel,  had  his  throat  violently  clenched  by  the  hand  of  a  vigorous 
adversary.  A£  the  moment  there  was  very  acute  pain,  and  the  sensa- 
tion of  a  solid  body  breaking.  The  pain  was  aggravated  by  every 
effort  to  speak,  to  swallow,  or  to  move  the  tongue,  and  when  this 
organ  was  pushed  backwards,  deglutition  was  impossible.  The  patient 
could  not  articulate  distinctly ;  and  he  was  unable  to  open  his  mouth 
without  exciting  a  great  deal  of  pain.  He  placed  his  hand  upon  the 
anterior  and  superior  part  of  his  neck  to  point  out  the  seat  of  the 
injury.  This  part  was  slightly  swollen,  and  presented  on  each  side 
small  ecchymoses,  one  above,  more  decided,  immediately  under  the  left 
angle  of  the  lower  jaw.  "  The  large  cornua  of  the  os  hyoides  was  very 
distinctly  to  the  right  side,"  and  it  could  be  felt  on  the  left  deeply  seated 
by  pressing  with  the  fingers ;  in  following  it  in  front  toward  the  body 
of  the  bone,  a  very  sensible  inequality  near  the  point  of  junction  of 
these  two  parts  could  be  perceived.  By  putting  the  finger  within  the 
mouth,  the  same  projections  and  cavities  inverted  could  be  felt,  and 
even  the  points  of  the  bone  which  had  pierced  the  mucous  membrane, 
&c.,  were  evident.  Having  bled  the  patient,  and  placed  a  plug  between 
his  teeth  to  keep  the  mouth  open,  the  broken  branch  was  brought  by 
the  finger  back  to  the  surface  of  the  body  of  the  bone,  and  easily  re- 
duced. The  position  of  the  head  inclined  a  little  back  ;  rest,  absolute 
silence,  diet  and  some  saturnine  fomentations,  composed  the  after- 
treatment.  To  avoid  a  new  dislocation,  by  the  efforts  of  swallowing, 
the  oesophagus  tube  of  Desault  was  introduced,  to  conduct  the  drinks 
and  liquid  aliments  into  the  stomach ;  this  sound  was  allowed  to  re- 
main until  the  twenty-fifth  day ;  at  this  time  the  patient  could  swallow 
without  pain,  and  began  to  take  a  little  more  solid  nourishment,  and 
at  the  end  of  two  months  the  cure  was  complete.  By  placing  a  finger 
within  his  mouth,  a  slight  nodosity  could  be  felt  in  the  place  where, 
in  the  recent  fracture,  the  splintered  points  were  perceptible.' 

Dieffenbach  has  also  recorded  a  fracture  of  the  great  right  horn,  pro- 
duced in  the  same  manner,  by  grasping  the  throat  between  the  thumb 
and  fingers,  which  occurred  in  a  girl  only  nineteen  years  old.  Very 
slight  pressure  upon  the  side  of  the  bone  was  sufficient  to  move  the 
fragment  inwards,  and  to  produce  a  crepitus,  but  it  immediately 
resumed  its  place  when  the  pressure  was  removed.  There  being, 
therefore,  no  displacement,  the  cure  was  effected  in  a  short  time 
without  resort  to  any  remedies  except  tisans  and  antiphlogistics.  She 
was  not  even  forbidden  to  speak.^ 

Auberge  saw  a  similar  case,  in  a  person  fifty-five  years  old,  occasioned 
by  grasping  the  throat.  The  fracture  was  in  the  great  horn  of  the  right 
side,  and  the  displacement  was  so  complete  that  crepitus  could  not  be 
felt,  and  the  mucous  membrane  of  the  pharynx  was  penetrated  by  the 
broken  bone.^ 

The  following  example  is  reported  by  Dr.  Wood,  of  Cincinnati, 
Ohio,  as  having  come  under  his  observation  in  the  year  1855 : — 

'  Amer.  Joui'n.  Med.  Sci.,  vol.  xiii.  p.  250. 

2  Medic.  Vereinszeitung  fur  Preussen,  1833,  No.  3 ;  Gazette  Med.,  1834,  p.  187. 

3  Revue  Med.,  July,  1835. 


1-10  FRACTUEES    OF    THE    HYOID    BONE. 

"Through  the  kindness  of  our  friend  Dr.  P.  G.  Fore,  of  this  city, 
we  were  invited  to  examine  a  case  of  fracture  of  the  os  hyoides,  that 
had  occurred  about  one  week  before  we  saw  it,  in  one  of  his  patients. 
The  patient  was  a  female,  about  thirty  years  of  age,  who  had  fallen 
down  the  cellar  steps,  striking  the  prominent  parts  of  the  larynx  and 
hyoid  bone  against  a  projecting  brick,  severely  injuring  the  larynx  as 
well  as  fracturing  the  bone. 

"The  fracture  was  on  the  left  side,  and  near  the  junction  of  the 
great  horn  with  the  body  of  the  bone.  Crepitation  was  distinctly  felt 
on  pressing  the  bone  between  the  thumb  and  finger;  or  when  the  pa- 
tient would  swallow ;  though,  at  this  time,  the  severe  symptoms  that 
followed  the  accident,  and  continued  for  several  days,  had  somewhat 
subsided. 

"Immediately  after  the  accident,  there  was  profuse  bleeding  from 
the  fauces,  and  she  experienced  great  difficulty  and  pain  in  the  act  of 
swallowing,  and  the  power  of  speech  was  almost  entirely  lost.  On 
attempting  to  depress  or  protrude  the  tongue,  she  felt  distressing 
symptoms  of  suffocation.  Considerable  inflammation  and  swelling  of 
the  throat  and  larynx  ensued,  and  continued  in  some  degree  up  to  the 
time  of  our  visit. 

"To-day  (about  four  weeks  since  the  accident)  Dr.  F.  informs  us 
that  the  patient  has  so  far  recovered  as  to  be  able  to  converse,  though 
the  voice  is  somewhat  impaired.  She  is  yet  unable  to  swallow  solid 
food,  and  is  wholly  sustained  by  fluids."' 

Mar^cinkovsky  saw  a  woman  in  whom  both  the  lower  jaw  and  the 
left  horn  of  the  os  hyoides  were  broken  by  a  fall  from  her  carriage 
against  a  wall.    She  died  in  about  twenty-four  hours  from  suftbcation.^ 

Dr.  Griinder  reports  the  following : — 

"  A  laborer,  set.  63,  fell  from  a  wagon  on  his  face,  and  discharged 
a  large  quantity  of  blood  by  the  mouth.  He  found  he  could  not  swal- 
low, and  when  seen  twelve  hours  afterward,  complained  of  severe  pain 
in  the  neck  and  nape,  with  inability  to  turn  his  head,  though  no  in- 
jury of  the  vertebrae  could  be  detected.  His  voice  was  hoarse  and 
difficult.  On  attempting  to  drink,  the  fluid  was  rejected  with  violent 
coughing,  the  patient  declaring  he  felt  it  as  if  entering  the  air-passages. 
An  examination  of  the  fauces  led  to  no  explanation  of  this  condition. 
The  epiglottis  did  not,  however,  appear  to  completely  close  the  larynx, 
or  to  be  in  its  exact  position.  The  tongue  was  movable  in  all  direc- 
tions, and  pressing  it  down  with  a  spatula  caused  no  inconvenience. 
The  hj'-oid  seemed  to  possess  its  continuity.  No  crepitation  or  abnor- 
mal movability  could  be  perceived,  and  no  pain  at  the  root  of  the  tongue 
occurred  on  attempting  to  swallow.  After  repeated  examinations,  the 
case  was  concluded  to  be  one  in  which  the  functions  of  the  nervus 
vagus  had  undergone  great  disturbance,  or  the  muscles  of  the  larynx 
had  become  torn  or  paralyzed.  Medicine  and  food  were  administered 
by  means  of  an  elastic  tube.  The  patient  had  a  good  appetite  and 
slept  well ;  the  pain  of  the  neck  was  lost,  and  its  motion  recovered ; 

'  Western  Lancet;  also  N.  Y.  Journ.  Med.,  vol.  xv.  p.  152. 

2  Medic.  Vereinszeitung,  fiir  Preussen,  1833,  No.  15  ;  Gazette  Medicale,  1833,  p. 
354. 


FRACTURES    OF    THE    HYOID    BONE.  141 

a  hectic  cough,  from  which  he  had  long  suffered,  alone  remaining. 
After  continuing,  however,  to  go  on  thus  well  for  six  days,  the  cough 
increased ;  the  appetite  failed ;  strength  was  lost;  the  voice  was  scarcely 
audible;  and  in  five  more  days  the  patient  died  exhausted.  At  the 
autopsy  a  fracture  of  the  os  hyoides  was  found.  One  of  the  large  cornua 
was  broken,  and  had  become  firmly  imbedded  between  the  epiglottis 
and  rima  glottidis,  inducing  the  raised  position  of  the  epiglottis,  loss 
of  voice,  and  difficulty  in  swallowing.  The  fracture  was  probably  pro- 
duced by  muscular  action,  a  cause  first  assigned  in  a  case  occurring 
to  OUivier  dAngers.'"  I  think  it  more  probable,  however,  that  this 
fracture  was  the  result  of  a  direct  blow,  than  of  muscular  action. 

In  the  case  referred  to,  however,  as  having  been  reported  by  OUi- 
vier, there  can  be  no  doubt  that  the  fracture  was  due  to  muscular 
action  alone. 

A  woman,  fifty-six  years  old,  made  a  misstep  and  fell  backwards, 
and  at  the  same  moment  that  her  head  was  thrown  violently  back,  she 
felt  distinctly  a  sensation  as  if  a  solid  body  had  broken  in  the  upper 
part  of  her  neck,  and  upon  its  left  side.  An  examination  showed 
that  she  had  fractured  the  great  left  horn  of  the  os  hyoides.  Inflam- 
mation and  suppuration  followed,  and  finally,  after  about  three  months, 
the  posterior  fragment  made  its  way  out  in  a  condition  of  necrosis,  and 
the  fistula  promptly  healed,  but  there  remained  for  many  years  a 
sense  of  uneasiness  about  these  parts  when  she  swallowed,  sometimes 
amounting  to  pain.^ 

Etiology. — Of  the  ten  cases  which  I  have  found  upon  record,  three 
were  produced  by  hanging;  three  by  grasping  the  throat  between  the 
thumb  and  fingers;  three  by  direct  blows,  or  by  falls  upon  the  front 
of  the  neck;  and  one  by  muscular  action  alone. 

The  observation  of  Mr.  South  that  fracture  of  the  bone  "  is  almost 
invariably  found"^  in  persons  executed  by  hanging,  is  probably  incor- 
rect, since  although  a  large  proportion  of  these  subjects  are  submitted 
to  dissection  both  in  this  and  other  countries,  yet  I  know  of  but  these 
three  examples  which  have  been  published. 

Pathology,  Symptomatology,  and  Diagnosis. — The  body  of  the  bone 
seems  to  have  been  broken  in  all  of  those  cases  which  resulted  from 
hanging:  while  in  all  of  the  other  examples  the  fracture  has  occurred  in 
one  of  the  great  horns,  or  at  the  junction  of  the  horns  with  the  body. 
Generally  the  displacement  inwards  of  one  of  the  fragments  has  been 
so  complete  that  crepitus  could  not  be  detected.  It  was  present,  how- 
ever, in  the  examples  mentioned  by  Dieffenbach  and  Wood.  In  two 
instances  the  mucous  membrane  has  been  penetrated,  and  in  one  the 
fragment  was  projected  between  the  epiglottis  and  rima  glottidis. 

The  accident  has  been  characterized  by  a  sudden  sensation  as  if  a. 
bone  had  broken ;  in  a  few  instances,  by  profuse  bleeding  from  the 
fauces;  by  difficulty  in  opening  the  mouth;  by  impossibility  of  deglu- 
tition, and  by  loss  of  voice  in  others ;  with  great  pain  in  moving  the 

'  Schimidt's  Jahrbuch.,  vol.  Ixvlii.  ;  also  Amer.  Journ.  Med.  Sci.,  vol.  xlix.  p.  253, 
Jan.  1852. 

2  Malg.,  op.  cit.,  p.  405. 

^  Note  to  Chelius'  Surgery,  Amer.  ed.,  vol.  i.  p.  581. 


142  FKACTUKES    OF    THE    HYOID    BONE. 

tongue,  the  pain  being  especially  at  its  root ;  in  one  instance  the 
tongue  was  perceptibly  drawn  to  one  side.  There  is  also  usually  more 
or  less  swelling  and  soreness  about  the  neck,  with  ecchymosis ; 
and  at  a  later  period,  cough,  expectoration,  hoarseness,  &c.  The  cir- 
cumstances which,  however,  indicate  certainly  the  nature  of  the  acci- 
dent, are  preternatural  mobility  of  the  fragments,  with  or  without  cre- 
pitus, and  the  angular,  inward  projection,  which  may  in  most  cases  be 
distinctly  felt  in  a  careful  examination  of  the  pharynx. 

In  the  case  related  by  Griiner,  the  only  symptoms  were  a  loss  of 
voice,  difficulty  of  deglutition,  and  a  sensation  when  the  attempt  was 
made  to  swallow,  as  if  the  fluids  passed  into  the  windpipe;  with  also 
an  imperfect  closure  of  the  epiglottis  upon  the  rima  glottidis.  No 
preternatural  mobility  or  irregularity  in  the  fragments  could  be  de- 
tected, nor  was  there  crepitus,  and  it  was  concluded  that  the  bone  was 
not  broken,  yet  the  autopsy  showed  that  the  fragment  was  imbedded 
deeply  between  the  epiglottis  and  the  rima  glottidis. 

Prognosis. — It  is  only  in  view  of  its  complications  that  this  accident 
can  be  regarded  as  serious ;  where  the  severity  of  the  injury  has  been 
such  as  to  fracture  the  lower  jaw  at  the  same  time,  as  in  the  case  re- 
lated by  Marcinkovsky,  or  such  as  to  bury  the  fragment  deep  in  the 
tissues  about  the  rima  glottidis  as  in  the  case  mentioned  by  Griiner,  a 
favorable  termination  could  scarcely  have  been  expected  ;  and  these 
are  the  only  cases  yet  published  in  which  the  death  was  in  any  way 
connected  with  the  fracture.  One-half  of  the  whole  number  have  died, 
but  of,  these,  three  have  died  by  hanging,  and  the  remaining  two  from 
the  causes  named.  Of  the  three  in  which  the  accident  resulted  from  a 
direct  blow,  only  the  patient  of  Dr.  Fore,  of  Cincinnati,  has  survived  ; 
while  of  the  three  whose  fractures  resulted  from  lateral  pressure  upon 
the  cornua,  all  recovered;  so,  also,  did  the  patient  in  whom  the  frac- 
ture was  produced  by  muscular  action. 

Treatment. — No  doubt  when  the  fragments  are  displaced  an  attempt 
ought  to  be  made  to  replace  them  by  introducing  one  finger  into  the 
mouth,  while  with  the  opposite  hand  the  fragments  are  supported  from 
without.  Lalesque  found  this  a  matter  of  some  difficulty,  but  Auberge 
experienced  no  difficulty  at  all.  I  suspect,  however,  that  the  amount 
of  difficulty  will  very  much  depend  upon  the  degree  of  displacement, 
and  the  consequent  laceration  of  the  soft  tissues  about  the  bone.  But 
however  this  may  be,  it  must  be  altogether  another  thing  to  be  able  to 
keep  in  exact  apposition  the  broken  ends  of  a  bone  whose  diameter  is 
so  inconsiderable  and  upon  which  it  is  quite  impossible  to  apply  auy 
apparatus  or  dressings  to  retain  the  fragments  in  place.  Lalesque 
threw  the  head  of  his  patient  slightly  back,  with  the  view  of  making 
"  permanent  extension"  upon  the  fragments  through  the  action  of  the 
muscles  and  ligaments  attached  to  the  bone,  and  he  recommends  this 
position  as  that  which  is  best  calculated  to  preserve  the  coaptation. 
Malgaigne  on  the  contrary,  without  having  himself  seen  any  example 
of  this  fracture,  believes  that  the  position  of  flexion  of  the  neck,  with 
.entire  relaxation  of  the  muscles,  would  be  most  suitable. 

In  all  cases  it  will  be  proper  to  enjoin  silence,  and  to  adopt  suitable 
measures  to  combat  inflammation  :  such  as  general  or  topical  bleeding, 


THYROID   AND    CRICOID    CARTILAGES.  143 

fomentations,  moistening  the  mouth  with  cool  water,  or  permitting  small 
pieces  of  ice  to  rest  in  the  mouth  until  dissolved,  without  in  general 
allowing  the  fluid  to  be  swallowed ;  but  in  some  examples,  no  doubt 
the  patient  may  be  permitted  to  swallow. 


CHAPTER   XIV. 

FRACTURE   OF  THE   CARTILAGES   OF  THE   LARYNX. 
§  1.  Thyroid  Cartilage. 

The  examples  of  fracture  of  the  larynx  which  may  be  found  upon 
record,  are  also  very  few.  M.  Ladoz  examined  the  larynx  of  a  man  who 
had  been  assassinated,  and  upon  whose  neck  he  found  a  handkerchief 
bound  so  tightly  as  to  leave,  after  its  removal,  a  deep  furrow ;  but  the 
neck  showed  also  distinct  marks  produced  by  the  fingers  Eftid  thumb. 
There  was  a  fracture  of  the  thyroid  cartilage  which  extended  obliquely 
downwards  and  outwards  through  its  right  wing.  The  whole  of  the 
larynx  was  very  much  ossified,  although  the  subject  was  only  thirty- 
seven  years  old.-" 

In  1823,  M.  Ollivier  communicated  to  the  Academy  of  Medicine  a 
case  in  which,  this  cartilage  being  broken,  the  patient  died  of  suffoca- 
tion.^ 

M.  Marjolin  says,  "  Two  women  at  the  hospital  being  engaged  in  a 
quarrel,  one  of  them  seized  her  antagonist  by  the  throat,  and  griped 
her  so  strong  that  she  broke  the  thyroid  cartilage  from  its  upper  to  its 
lower  margin.  You  will  imagine  that  it  was  not  very  difficult  to  de- 
termine the  existence  of  a  fracture,  and  that  no  retentive  apparatus 
was  demanded.  Silence,  regimen,  a  small  bleeding,  and  the  cure  was 
accomplished."^ 

These  are  the  only  cases  of  fracture  of  the  cartilages  of  the  larynx 
of  which  we  have  any  precise  account,  in  which  the  thyroid  cartilage 
was  alone  involved. 


§  2.  Thyroid  and  CRicorD  Cartilages. 

Plenck  saw  a  fracture  of  both  the  thyroid  and  cricoid  cartilages  pro- 
duced by  falling  upon  the  rim  of  a  pail."  Morgagni  also  says  that  he 
had  seen  fractures  of  the  larynx ;  and  Eemer  mentions  a  fracture  of 

'  Gazette  Medicale,  1838,  p.  698. 
^  Archives  Generales  de  Medecine,  tome  ii.  p.  3U7. 
^  Marjolin,  Cours  de  Patholog.  Cliir.,  p.  396. 
*  Malg.,  op.  cit.,  p.  409. 


144       FRACTURE    OF    THE    CARTILAGES    OF    THE    LARY]Srx. 

the  larynx  found  in  a  person  who  had  been  hanged  ;^  but  in  neither 
case  is  it  said  in  which  cartilage  the  fracture  occurred,  or  whether  it 
had  not  occurred  in  both. 

I  am  able,  however,  to  furnish  from  my  own  observation  another 
example  of  fracture  of  both  cartilages : — 

John  Calkins,  of  Collins,  Erie  Co.,  N.  Y.,  get.  41,  is  supposed  to  have 
been  kicked  by  a  young  horse  on  the  10th  of  Nov.,  1S56.  He  was 
alone  in  the  stables  when  the  accident  occurred,  and  being  stunned 
by  the  blow,  he  could  not  himself  give  any  account  of  the  manner  in 
which  the  injury  was  received.  When  found  he  was  sitting  upright, 
but  unable  to  articulate,  except  in  a  whisper.  Drs.  Barber  and  Davis, 
of  Colden,  saw  him  about  two  hours  after.  His  countenance  was 
anxious;  his  pulse  feeble;  extremities  cold;  and  he  was  breathing 
with  great  difficulty.  A  small  quantity  of  blood  was  issuing  from  his 
fauces.  His  upper  lip  was  cut  and  a  few  of  his  teeth  dislocated  :  the 
wound  appearing  as  if  inflicted  by  one  of  the  corks  of  the  horse's  shoes. 
There  was  no  other  wound  ;  but  over  the  left  wing  of  the  thyroid  car- 
tilage there  was  a  slight  discoloration,  pressure  upon  which  produced 
intense  pain  and  sufibcation,  and  disclosed  the  fact  that  the  thyroid 
prominence  was  depressed  very  much  and  broken.  Cold  lotions  were 
directed  to  be  applied,  and  as  the  thirst  was  excessive,  but  deglutition 
impossible,  he  was  permitted  to  hold  pieces  of  ice  in  his  mouth.  This 
plan,  with  but  slight  modifications,  such  as  the  substitution  of  warm 
fomentations  to  the  neck  for  the  cold  lotions,  was  continued  until  the 
following  evening,  when,  at  the  request  of  the  attending  physician,  Dr. 
Barber,  I  was  called  to  see  him.  The  symptoms  remained  nearly  the 
same  as  at  first.  He  was  unable  to  speak  audibly,  or  perform  the 
act  of  deglutition ;  his  breathing  was  difficult  and  at  times  threatened 
suffocation.  The  lateness  of  the  hour,  with  other  circumstances,  deter- 
mined me  to  defer  surgical  interference  until  morning.  At  daybreak 
of  the  12th  I  made  the  operation  of  laryngotomy,  and  introduced  a 
large  double  canula  into  the  crico-thyroidean  space.  This  operation 
was  rendered  difficult  by  the  great  amount  of  swelling  about  the  neck, 
due  both  to  emphysema,  and  bloody  with  serous  infiltrations.  The 
breathing  immediately  became  easy,  and  gradually  the  appearance  of 
asphyxia  disappeared  from  his  face ;  but  after  about  six  or  seven 
hours,  he  began  perceptibly  to  fail  in  strength,  and  died  at  3  o'clock 
P.  M.,  of  the  following  day,  apparently  from  exhaustion  rather  than 
from  suffocation:  having  survived  the  accident  about  seventy-two 
hours,  and  the  operation  about  thirty-four  hours. 

The  autopsy  disclosed  a  comminuted  fracture  of  the  thyroid  carti- 
lage, with  a  simple  fracture  of  the  cricoid.  The  thyroid  was  broken 
almost  perpendicularly  through  its  centre  ;  the  line  of  fracture  being- 
irregular,  and  inclining  slightly  to  the  left  side.  The  left  inferior  horn 
was  broken  o&  about  three  lines  from  its  articulation  with  the  cricoid 
cartilage.  The  right  ala  was  broken  also  in  a  line  nearly  vertical,  but 
irregular,  at  a  point  about  six  lines  from  its  posterior  margin.  The 
pomum  Adami  was  depressed  to  the  level  of  the  cricoid  cartilage,  and 

'  Morgagni,  de  Sedibus,  etc.,  Epist.  19,  num.  13, 14  et  16  ;  Reiner,  Annales  d'hygiene, 
tome  iv.  p.  171  ;  from  Malg. 


CRICOID    CARTILAGE.  14:5 

the  left  ala,  being  completely  detaclied,  was  thrown  inwards  and  up- 
wards several  lines.  Underneath  the  perichondrium,  especially  upon 
the  inner  side,  there  was  pretty  extensive  bloody  infiltration.  Ossifi- 
cation of  the  cartilages  had  commenced  at  several  points,  but  it  had 
made  but  little  progress.  The  central  fracture  of  the  thyroid  was 
through  cartilage  alone.  The  fracture  of  the  right  ala  was  through 
cartilage  until  it  reached  a  bony  belt  comprising  the  two  inferior  lines 
of  its  course.  The  left  lower  horn  was  ossified,  and  the  fracture  was 
through  this  bony  structure.  The  fracture  through  the  cricoid  carti- 
lage commenced  close  upon  the  margin  of  a  bony  plate,  but  in  its 
whole  course  it  traversed  only  cartilage.  It  was  on  the  left  side. 
There  was  also  an  incomplete  fracture  on  the  right  ala  of  the  thyroid 
cartilage,  commencing  in  the  line  of  the  principal  fracture  and  ex- 
tending obliquely  downwards  about  three  lines,  until  it  was  arrested 
by  the  bony  plate  which  constituted  the  lower  margin  of  this  wing. 

A  ragged,  lacerated  wound  in  the  back  of  the  larynx,  above  the 
cricoid  cartilages,  communicated  directly  with  the  oesophagus. 


§  3.  Cricoid  Cartilage. 

Both  Valsalva  and  Cazauvieilh  have  each  met  with  a  single  exam- 
ple of  this  fracture,  without  fracture  of  the  thyroid  cartilage ;  and 
Weiss  has  found  the  cricoid  cartilage  broken  into  numerous  frag- 
ments, and  at  the  same  time  separated  from  the  trachea.^ 

General  Etiology  of  Fractures  of  the  Laryngeal  Carti- 
lages.— As  a  predisposing  cause,  advanced  age,  with  its  usual  con- 
comitant, partial  or  complete  ossification  of  the  cartilages,  has  been 
thought  to  occupy  a  prominent  place.  The  number  of  recorded  cases 
is,  however,  too  small  to  establish  its  actual  value.  In  the  case  reported 
by  Plenck.  the  cartilages  were  already  very  much  ossified,  although  the 
subject  was  only  thirty-seven  years  old.  Morgagni  observed  that  in  his 
experience  it  had  occurred  always  in  advanced  life.  In  my  own  case, 
however,  the  cartilages  were  only  slightly  ossified,  the  patient  being 
forty-one  years  old;  nor  did  the  lines  of  the  several  fractures  indicate  a 
preference  for  the  bony  plates;  but  it  seems  to  me  that  they  rather  avoided 
them,  and  in  the  case  of  the  incomplete  fracture,  the  bone  appeared 
to  have  arrested  the  fracture.  In  fact,  a  few  experiments  have  satisfied 
me  that  the  adult  laryngeal  cartilages  are  quite  as  brittle  as  bone, 
and,  consequently,  that  ossification  in  no  way  increases  their  liability 
to  fracture. 

The  immediate  causes  have  been  direct  blows,  as  falling  upon  the 
edge  of  a  pail,  a  kick  from  a  horse,  or  pressure,  as  in  hanging,  or  in 
grasping  the  larynx  strongly  between  the  thumb  and  fingers. 

General  Symptomatology,  etc. — The  signs  of  this  accident  are 
such  as  usually  attend  any  severe  injury  of  this  organ,  whether  accom- 
panied with  a  fracture  or  not,  such  as  pain,  swelling,  difficult  degluti- 

'  Malg.,  op.  cit.,  p.  408. 

10 


146       FEACTURE    OF    THE    CARTILAGES    OF    THE    LARYNX. 

tion,  embarrassed  respiration,  a  loss  of  voice,  cough,  and  perhaps 
bloody  expectoration,  with  emphysema,  &c. 

But  none  of  these  can  be  regarded  as  diagnostic ;  although,  when 
taken  in  connection  with  the  history  of  the  accident,  especially  if  a 
very  severe  and  direct  blow  has  been  received,  or  more  certainly  still, 
when  symptoms  so  grave  and  complicated  have  followed  an  attempt 
at  strangulation  by  grasping  the  throat,  they  may  be  regarded  as  pro- 
bable or  presumptive  evidences. 

A  positive  diagnosis  must  depend  upon  the  presence  of  a  sensible 
displacement,  or  motion  of  the  fragments,  with  crepitus. 

In  the  case  related  by  Plenck,  death  followed  almost  immediately, 
with  convulsions,  and  without  any  outcry ;  indicating,  probably,  some 
severe  lesion  of  the  spinal  marrow;  while  in  M.  Ollivier's  patient  suffo- 
cation ensued,  at  first  intermittent,  and  finally  permanent. 

In  my  own  case,  suffocation  was  throughout  a  prominent  symptom, 
with  only  such  slight  intervals  of  amelioration  as  might  have  been 
occasioned  by  the  extrication  of  the  blood  or  mucus  from  the  larynx. 

General  Prognosis, — The  prognosis  ought  to  depend  rather  upon 
the  complications  and  upon  the  gravity  of  the  symptoms,  than  upon 
the  simple  decision  of  the  question  of  fracture.  A  fracture  produced 
by  grasping  the  wings  of  the  thyroid  cartilage,  and  without  any  great 
contusion  or  laceration  of  the  soft  parts,  might  reasonably  be  expected 
to  terminate  favorably  under  judicious  management;  but  when,  on  the 
contrary,  the  fracture  is  the  result  of  great  violence  inflicted  directly 
upon  the  front  of  the  cartilages,  producing  severe  contusion  and  lace- 
ration, and  is  followed  by  great  swelling,  very  difficult  respiration, 
complete  aphonia,  impossibility  of  deglutition,  &;c.,  the  prognosis  can- 
not but  be  unfavorable — and  indeed  the  woman  spoken  of  by  Marjolin, 
whose  larynx  was  broken  by  grasping  the  neck,  is  the  only  one,  so 
far  as  we  know,  whose  recovery  has  been  mentioned. 

General  Treatment, — In  examples  of  simple,  uncomplicated  frac- 
ture, "silence,  regimen  and  a  small  bleeding,"  may  suffice;  but  in  other 
cases,  it  may  become  necessary  to  introduce  a  tube  into  the  stomach 
to  supply  the  patient  with  food  and  drinks,  since  deglutition  may  be 
impossible.  If  also,  suffocation  is  imminent,  there  may  remain  no 
alternative  but  a  resort  to  tracheotomy,  or  to  laryngotomy.  I  am  not 
aware  that  this  has  ever  been  practised  except  by  myself,  yet  its  pro- 
priety, under  certain  conditions,  is  sufficiently  manifest. 

As  to  a  "reduction"  of  the  fragments,  by  manipulation,  I  believe  it 
will  be  found  generally,  if  not  always,  impracticable.  "Whatever  dis- 
placement exists  must  be  mostly  inwards,  and  we  can  have  no  means  of 
forcing  them  again  outwards.  Nor  if  once  replaced,  do  I  see  any  reason 
to  suppose  that  they  would  not  become  immediately  displaced. 

Chelius  has  suggested  the  propriety,  in  such  cases,  of  cutting  open 
the  coverings  of  the  larynx  freely  in  the  mesian  line,  and  after  stanch- 
ing the  bleeding,  proceeding  at  once  to  divide  the  larynx  itself  in  its 
whole  length  and  then  replacing  the  broken  cartilages'.     The  pro- 

'  System  of  Surgery,  Philadelphia  ed.,  vol.  i,  p,  581,  1847. 


FEACTUEES    OF    THE    SPIXOUS    PEOCESSES. 


147 


cedure  has  an  aspect  of  severity,  but  I  can  well  conceive  of  circum- 
stances which  would  justify  its  adoption;  not,  however,  so  much  for  the 
purpose  of  replacing  the  cartilages,  as  for  the  purpose  of  arresting  a 
fatal  internal  hemorrhage,  and  of  giving  a  free  admission  of  air  to  the 
lungs.  If  this  operation  were  to  be  practised,  the  wound  ought  to  be 
left  open  for  a  sufficient  length  of  time  to  allow  of  the  subsidence  of  the 
inflammation,  and  then  permitted  to  close  with  such  precautions  as  expe- 
rience teaches  are  usually  necessary  after  the  windpipe  has  been  opened. 

Active  antiphlogistic  measures,  combined  with  fomentations  to  the 
neck,  so  far  as  these  latter  are  found  to  be  agreeable  and  practicable, 
are  important  measures,  and  not  to  be  overlooked  in  the  general  plan 
of  treatment. 

My  own  patient,  also,  found  small  pieces  of  ice,  permitted  slowly  to 
dissolve  in  the  mouth,  very  grateful ;  but  he  preferred  very  much  as 
an  external  application,  the  warm  fomentations  to  the  cold  lotions. 


CHAPTER    XV. 

FEACTUEES    OF    THE  TEETEBE.^. 

It  will  be  convenient  to  divide  fractures  of  the  vertebrae  into  frac- 
tures of  the  spinous  processes,  transverse  processes,  vertebral  arches 
and  bodies. 


Fig.  31. 


§  1.  Fkactures  of  the  Spixors  Processes. 

Fractures  of  the  spinous  apophyses,  independent  of  a  fracture  of  the 
arches,  may  occur  at  any  point  of  the  vertebral  column;  and  they  may 

be  occasioned  by  a  blow  received  upon 
either  side  of  the  spinal  column;  or  by 
a  force  directed  from  above  or  from 
below. 

Sympto^ms  and  Pathology. — These  ac- 
cidents may  be  recognized  by  the  lively 
pain  at  the  point  of  fracture,  produced 
especially  when  the  patient  bends  for- 
wards, which  position  renders  the  skin 
and  muscles  tense  and  drives  the  frag- 
ments into  the  flesh ;  by  the  swelling, 
tenderness  and  discoloration ;  but  chiefly 
by  the  lateral  displacement  of  the  broken ' 
process,. and  the  mobility. 

Duverney  met  with  a  fracture  of  two 
Fracture  of  the  spinous  process.  of  the  proccsses  in  the  samc  pcrsou,  and 


14:8  FRACTURES  OF  THE  VERTEBRA. 

which  could  only  be  recognized  by  the  mobility,  since,  as  the  autopsy 
proved,  there  was  no  displacement.  Nor  would  it  be  surprising  if  the 
displacement  was  absent  in  a  majority  of  these  accidents,  inasmuch  as 
the  attachment  of  the  ligaments  from  above  and  below  with  the  strong 
and  short  muscles  upon  either  side,  must  prevent  a  deviation  in  any 
direction  until  these  tissues  were  more  or  less  torn.  Sir  Astley  men- 
tions a  case  in  which,  however,  such  lacerations  did  occur,  and  the 
lateral  deformity  was  quite  conspicuous. 

A  boy  had  been  endeavoring  to  support  a  heavy  weight  upon  his 
shoulders,  when  he  fell,  bent  double.  Immediately  he  had  the  appear- 
ance of  one  suffering  under  a  distortion  of  the  spine  of  long  standing. 
Three  or  four  of  the  processes  were  broken  off  and  the  corresponding, 
muscles  were  detached  so  as  to  allow  the  processes  to  fall  off  to  the 
opposite  side.  There  was  no  paralysis,  and  he  was  soon  discharged 
with  the  free  use  of  his  limbs,  but  the  deformity  remained.^ 

If  the  fragment  is  thrown  directly  downwards,  as  it  possibly  may 
be,  especially  in  the  cervical  or  lumbar  region,  yet  not  without  a  rup- 
ture of  the  supra-spinous  ligaments,  or  of  the  ligamentum  nuchse,  then 
the  displacement  will  be  more  difficult  to  detect,  and  it  may  require 
some  more  care  not  to  confound  it  with  a  fracture  of  the  vertebral  arch 
or  of  the  plates  from  which  the  spinous  processes  arise.  The  process 
not  being  felt  in  its  natural  position,  nor  upon  either  side,  it  may  seem 
to  have  been  forced  directly  forwards,  when  in  fact  it  is  only  thrown 
downwards  towards  its  fellow.  The  danger  of  error  in  the  diagnosis 
will  be  increased  when  to  these  conditions  are  added  paralysis  of  those 
portions  of  the  body  which  are  below  the  seat  of  the  fracture,  and 
which,  in  this  case,  may  be  the  result  of  an  extravasation  of  blood  or 
of  simply  a  concussion  of  the  spinal  marrow.  Nor  do  I  think  it  would 
be  possible  now  to  determine  positively  whether  it  was  simply  a  frac- 
ture of  a  spinous  process,  of  the  arch,  or  of  the  body  itself  of  the  ver- 
tebra. In  case,  however,  the  paralysis  results  from  concussion,  the 
fact  will  in  most  cases  soon  become  apparent  by  a  return  of  sensation 
and  of  the  power  of  motion. 

Prognosis. — Hippocrates  affirmed  that  here,  as  in  fractures  of  other 
spongy  bones,  the  union  took  place  speedily.  It  is  quite  probable 
that  this  venerable  father  of  surgery  has  stated  the  fact  correctly,  and 
yet  in  the  only  example  known  to  me  where  the  condition  of  this 
process,  as  proved  by  dissection,  has  been  carefully  stated,  the  frag- 
ment had  not  united  by  bone  at  all.  This  is  the  case  related  by  Sir 
Astley  as  having  been  examined  by  Mr.  Key.  A  subject  was  brought 
into  the  dissecting  room  in  which  one  of  the  processes  had  been  broken, 
and,  on  dissection,  a  complete  articulation  was  found  between  the 
broken  surfaces,  which  surfaces  had  become  covered  with  a  thin  layer 
of  cartilage.  The  false  articulation  was  surrounded  with  synovial 
membrane  and  capsular  ligaments,  and  contained  a  fluid  like  synovia.^ 

Ordinarily  the  displacement  continues,  whatever  treatment  may  be 
adopted ;  but  Malgaigne  says  he  has  seen  one  instance  in  which  the 
twelfth  dorsal  spine  being  broken  and  displaced  laterally,  resumed  its 

'  Sir  Astley  Cooper,  op.  cit.,  p.  459.  ^  A.  Cooper,  op.  cit.,  p.  459. 


FRACTUEES  OF  THE  TRANSVERSE  PROCESS.       149 

place  spontaneously  after  a  few  days.     Aurran  mentions  a  similar 
example.' 

Treatment. — If  in  any  case  it  should  be  found  possible  to  act  upon 
the  fragment,  an  attempt  might  be  made  to  press  it  into  place,  and  to 
retain  it  there  by  means  of  a  compress  and  bandage ;  but  even  this 
would  not  be  admissible  so  long  as  any  doubt  remained  whether  it 
was  not  a  fracture  of  the  vertebral  arch,  since  if  it  were,  any  attempt 
to  restore  the  bone  to  place  by  pressure  would  be  likely  to  drive  it 
more  deeply  upon  the  spinal  marrow.  Yet  what  need  is  there  of 
surgical  interference  of  any  kind  ?  If  the  apophysis  remains  displaced 
it  cannot  result  in  any  serious,  perhaps  we  may  say  in  any  appreciable 
deformity.  The  surgeon  has  therefore  only  to  lay  the  patient  quietly 
in  bed  and  in  such  a  position  as  he  finds  most  comfortable,  enjoining 
upon  him  perfect  rest,  and  employing  such  other  means  as  may  be 
proper  to  combat  inflammation. 


§  2.  Fractures  or  the  Transverse  Process. 

A  fracture  of  a  transverse  process  can  scarcely  occur  except  as  a 
consequence  of  a  gunshot  wound.  Dupuytren  relates  a  case  of  this 
kind  in  which  the  ball  had  penetrated  the  transverse  process  of  the 
second  cervical  vertebra.  The  man  bled  very  little  at  the  time,  and 
his  symptoms  progressed  favorably  for  ten  days;  after  which  second- 
ary hemorrhage  occurred,  of  which  he  ultimately  died.  The  autopsy 
showed  that  the  vertebral  artery  had  been  injured,  and  that  the  inflam- 
mation of  its  coats  being  followed  by  a  slough,  caused  his  death.^ 

I  have  also  elsewhere  reported  the  case  of  Charles  Harkner,  of  this 
city,  who  was  shot  with  a  pistol  on  the  21st  of  Jan.,  1851.  I  did  not 
see  him  until  the  following  day.  The  ball  had  entered  the  chin,  a  little 
to  the  left  side  and  below  the  inferior  maxilla,  but  its  place  of  lodgment 
could  not  be  discovered.  He  lay  with  his  face  constantly  turned  to 
the  right.  The  left  side  of  his  neck  was  swollen  and  crepitant;  the  left 
arm  and  leg  were  paralyzed ;  he  slept  most  of  the  time,  but  could  be 
easily  aroused,  and  when  aroused  he  seemed  to  be  conscious,  but  was 
unable  to  speak.  By  signs  he  indicated  to  us  that  he  was  suffering 
no  pain.  He  gradually  sank,  without  hemorrhage,  and  died  in  thirty- 
six  hours  from  the  time  of  the  receipt  of  the  injury. 

The  autopsy,  made  four  hours  after  death,  enabled  us  to  trace  the 
wound  from  the  chin,  through  the  left  ala  of  the  thyroid  cartilage,  and 
also  through  the  roots  of  the  transverse  process  of  the  fourth  cervical 
vertebra ;  immediately  behind  which,  lying  embedded  in  the  muscles, 
was  the  bullet.  The  cavity  of  the  tunica  arachnoides  contained  con- 
siderable serous  effusion. 

The  emphysema  in  the  neck  was  occasioned,  no  doubt,  by  the 
wound  of  the  larynx,  the  ball  having  opened  freely  into  its  cavity. 
This  circumstance  also  explained  the  aphonia;   but  the  immediate 

•  Malgaigne,  op.  cit.,  p.  412. 

2  Dupuytren,  Diseases,  &c.,  of  Bones,  Syd.  ed.,  p.  360. 


150 


FEACTURES    OF   THE    VERTEBE,^. 


cause  of  his  death  seems  to  have  been  arachnoid  effusion  as  a  result  of 
meningeal  inflammation. 

The  symptoms  arising  from  this  accident  can  only  refer  to  the  com- 
plications, since  a  mere  fracture  of  the  process  is  not  likely  to  present 
any  peculiar  signs  which  could  be  recognized.  Concussion  or  bloody 
effusions  may  take  place  so  as  to  occasion  more  or  less  paralysis,  or, 
at  a  later  period,  inflammation  and  its  consequent  effusions  may  give 
rise  to  the  same  phenomenon. 

In  itself  considered,  and  independent  of  these  complications,  it  is 
sufficiently  trivial,  but  inasmuch  as  it  has  not  been  known  to  occur 
except  from  gunshot  wounds,  nor  is  it  likely  to  occur  except  from 
penetrating  wounds  of  some  kind,  the  accident  must  always  be  re- 
garded as  exceedingly  grave,  if  not  actually  fatal. 

As  to  the  treatment,  nothing  but  strict  rest  and  antiphlogistic  reme- 
dies can  prove  of  any  service. 


Fig.  32. 


§  3.  Fractures  of  the  Vertebral  Arches. 

The  vertebral  arches,  upon  which  both  the  spinous  and  transverse 
processes  have  their  principal  support,  may  be  broken  at  any  point  of 

their  circumference,  by  a  blow  received 
upon  the  spinous  process ;  but  generally 
it  is  the  lamellar  portion,  or  the  "  ver- 
tebral plate,"  which  gives  way  rather 
than  the  neck  or  pedicle  of  the  arch ; 
and  in  all  of  the  cases  recorded  the 
plates  have  been  broken  upon  both 
W"       i      Jlj^      "^  sides. 

>^  I    f  On  the  first  of  May,  1851,  during  a 

^^  violent  storm  of  wind  and  rain,  a  balus- 

trade  fell  from  the  top  of  a  high  build- 
ing, striking  a  man  named  John  Larkin, 
who  was  about  forty  years  of  age,  upon 
the  back  of  his  head  and  neck.  He  fell 
to  the  ground  instantly,  and  did  not 
again  move  his  feet  or  legs,  although 
he  never  lost  his  consciousness  until  he 
died.  I  found  the  bladder  paralyzed  also,  and  his  left  arm,  but  his 
right  arm  he  could  move  pretty  well.  He  conversed  freely  up  to  the 
last  moment,  and  said  that  he  was  suffering  a  good  deal  of  pain,  which 
was  always  greatly  aggravated  by  moving.  His  death  took  place 
thirty-six  hours  after  the  receipt  of  the  injury. 

Dr.  Hugh  B.  Vandeventer,  who  was  the  attending  surgeon,  made  a 
dissection  on  the  following  day  in  my  presence,  which  disclosed  the  fact 
that  the  plates  of  the  sixth  cervical  vertebra  were  broken  upon  each  side, 
and  that  the  spinous  process  with  a  small  portion  of  the  arch  attached 
was  forced  in  upon  the  spinal  marrow.  There  was  no  blood  effused, 
or  serum  at  this  point,  but  about  one  ounce  of  serum  was  found  in 
the  cavity  of  the  tunica  arachnoides  at  the  base  of  the  brain.     The 


Fracture  of  the  vertebral  arches. 


FRACTURES  OF  THE  VERTEBRAL  ARCHES.       151 

bodies  of  the  vertebrge  were  not  broken.  It  was  our  opinion,  there- 
fore, that  the  immediate  cause  of  his  death  was  the  direct  pressure  of 
the  spinous  process. 

In  the  case  related  by  Prout,  of  Alabama,  the  man  having  died  with- 
in forty-eight  hours  after  the  receipt  of  the  injury,  the  arch  of  the  fifth 
cervical  vertebra  was  found  to  be  broken  in  three  places,  and  the 
spinous  process  was  driven  in  upon  the  spinal  marrow.  There  was 
a  slight  efi"usion  of  blood  between  the  sheath  of  the  spinal  marrow  and 
the  bone,  and  a  considerable  efi"usion  between  the  sheath  and  the  cord. 
There  was  no  material  lesion  of  the  cord  or  of  its  membranes,  and  the 
body  of  the  bone  was  neither  broken  nor  dislocated. ■* 

It  is  probable,  also,  that  in  the  following  example  the  arch  was 
broken,  but  that  the  force  of  the  blow  having  been  somewhat  oblique, 
the  process  was  but  little  if  at  all  thrown  in  upon  the  spinal  marrow. 

R.  L.,  of  this  county,  aged  about  forty  years,  was  thrown  from  a 
loaded  wagon  in  February  of  1851,  striking,  as  he  thinks,  upon  the 
back  of  his  neck.  He  was  stunned  by  the  injury,  and  remained  insen- 
sible several  hours;  on  the  return  of  consciousness,  he  found  that  his 
lower  extremities  and  bladder  were  paralyzed.  During  four  weeks 
his  bladder  had  to  be  emptied  by  a  catheter.  Nine  months  after  the 
injury  was  received  he  consulted  me,  and  I  found  the  spinous  process 
of  the  last  cervical  vertebra  pushed  over  to  the  left  side.  His  head  was 
strongly  bent  forwards,  and  he  was  unable  to  straighten  it.  He  could 
walk  a  few  steps,  but  not  without  great  fatigue;  and  he  suffered  almost 
constant  pain  in  his  lower  extremities,  accompanied  with  excessive 
restlessness  and  watchfulness,  for  which  he  was  obliged  to  take  mor- 
phine in  large  quantities. 

In  the  case  related  by  Alban  Gr.  Smith,  of  Kentucky,  to  which  I 
shall  refer  again  presently,  the  deviation  was  lateral,  and  so  also  in 
Ollivier's  case,  mentioned  by  Malgaigne. 

Symptoms. — We  can  imagine  a  case  of  fracture  of  the  vertebral  arch, 
with  a  lateral  displacement  only,  in  which  the  symptoms  might  not 
differ  essentially  from  a  simple  fracture  of  the  spinous  process ;  and 
it  is  quite  possible  that  some  of  the  cases  which  have  been  supposed 
to  be  examples  of  this  latter  accident,  and  in  which  a  speedy  recovery- 
has  taken  place,  were  really  examples  of  fracture  of  the  arches  ;  yet  it 
must  be  admitted  that  such  a  fortunate  result  is  only  possible,  since 
the  arches  can  hardly  be  broken  without  communicating  a  severe 
concussion  to  the  marrow,  nor  without  lacerations,  inflammation,  and 
effusions,  which  will  be  most  certain  to  produce  compression  and 
paralysis,  and  probably  death. 

If,  however,  it  is  possible  for  us  to  confound  a  fracture  of  the  process 
with  a  fracture  of  the  arches,  it  is  still  more  possible  for  us  to  confound 
a  fracture  of  the  arches  with  a  fracture  of  the  bodies  of  the  vertebrae. 
If,  as  is  usually  the  fact,  the  process,  in  case  of  a  fracture  of  the  arch, 
is  less  prominent  than  natural,  and  that  portion  of  the  body  receiving 
its  nervous  supply  from  below  this  point  is  paralyzed,  we  may  have 

'  Front,  Amer.  Jonrn.  Med.  Sci,,  Nov.  1837,  vol.  xxi.  p.  276,  from  "Western  Journ. 
of  Med.  and  Phys.  Sci. 


152  FRACTUEES  OF  THE  VERTEBRA. 

reasons  to  believe  that  tbe  arch  is  broken  and  the  process  driven  in 
upon  the  spine ;  but  dissections  have  shown  that  in  many  of  these 
cases,  or  in  most  of  them  indeed,  the  bodies  of  more  or  less  of  the 
vertebrae  are  broken  also,  and  in  still  other  cases  the  bodies  were 
alone  broken. 

If,  as  in  the  case  mentioned  by  Ollivier,  we  can  feel  the  plates  move 
separately,  the  diagnosis  might  be  made  out,  so  far  at  least  as  to  deter- 
mine that  the  plates  were  broken ;  but  we  should  be  still  unable  to 
say  that  the  bodies  of  the  vertebrae  were  not  broken  also. 

Something  perhaps  may  be  inferred  from  the  direction  and  manner 
of  the  blow  which  has  produced  the  fracture.  Thus  a  fall  upon  the 
top  of  the  head  would  most  often  produce  a  comminution  of  the  bodies 
by  crushing  them  together,  while  a  blow  upon  the  back  could  scarcely 
break  one  of  the  vertebrae  without  breaking  the  corresponding  arch 
also.  We  might  thus  be  led  to  infer,  in  the  first  instance,  that  the 
arches  were  not  broken;  and,  in  the  second  instance,  if  we  could  con- 
vince ourselves  that  the  arches  were  not  broken,  we  might  rest  pretty 
well  assured  that  the  bodies  were  not. 

In  the  case  related  by  Prout,  there  was  no  external  mark  of  injury 
over  the  point  of  fracture,  but  a  distinct  crepitus  was  perceptible  on 
pressure. 

Treatment. — If  the  fragments  are  not  displaced,  nothing  but  rest  and 
a  cooling  regimen  are  indicated;  but  if  they  are  forced  in  upon  the 
marrow,  an  important  question  is  presented,  and  which  has  received 
from,  different  surgeons  different  solutions.  Shall  an  efibrt  be  made 
to  reduce  the  fragments  ?  and  if  so,  by  what  means  shall  the  indica- 
tion be  attempted  ? 

It  will  be  remembered  that  in  nearly  all  of  these  cases  we  must 
remain  in  doubt,  even  after  the  most  careful  examination,  as  to  the 
actual  condition  of  the  fracture.  It  may  be  that  what  we  suppose  to 
be  a  fracture  of  the  arch  is  only  a  fracture  of  the  apophysis,  or  that  on 
the  other  hand  it  is  a  fracture  of  the  body  of  the  bone  itself,  and  if  we 
are  expert  enough  to  make  out  clearly  a  fracture  of  the  arch,  it  is  not 
possible  for  us  to  say  that  the  body  is  not  broken  also,  indeed  it  is 
quite  probable  that  it  is  broken.  With  a  diagnosis  so  uncertain,  can 
we  ever  find  a  justification  for  surgical  interference?  Mr.  Oline  and 
Mr.  Cooper  thought  that  we  might.  According  to  them,  the  case  pre- 
sents in  no  other  direction  a  point  of  hope  or  encouragement.  Death 
is  inevitable,  sooner  or  later,  if  the  fragment  is  not  lifted,  and  we  can 
scarcely  make  the  matter  any  worse  by  interference.  If  it  proves  to 
be  a  fracture  of  the  apophysis,  as  happened  to  be  the  case  in  a  patient 
upon  whom  Sir  Astley  operated,'  our  interference  was  unnecessary, 
but  it  has  done  no  harm.  If  the  body  of  the  bone  is  broken,  the  ope- 
ration affords  no  resource,  but  the  patient  is  probably  beyond  suffering 
damage  at  our  hands.  If  the  diagnosis  is  correctly  made  out  and  the 
arch  only  is  broken,  and  if,  as  was  the  fact  in  the  case  of  Larkin  already 
mentioned,  there  is  no  bloody  effusion,  or  laceration  of  the  membranes 
or  of  the  marrow,  and  if  the  concussion  was  not  sufficient  to  deter- 

'  Cheliiis,  Surgery,  Amer.  ed.,  note  by  South,  vol.  i.  p.  592. 


FRACTURES  OF  THE  VERTEBRAL  ARCHES.       153 

mine  much  inflammation  of  the  cord,  then  it  would  seem  possible  that 
an  operation  might  save  the  patient. 

Paulus  ^gineta  first  suggested  that  the  compressing  fragments 
ought  to  be  removed  by  excision;  and  in  1762  Louis  removed  from 
a  man  who  had  received  a  gunshot  wound  in  his  back,  after  the  Inpse 
of  five  days,  several  loose  pieces  of  bone  belonging  to  the  arch  of  the 
vertebra,  and  the  patient  recovered,  but  not  without  a  partial  para- 
lysis of  his  lower  extremities.  Of  course  nothing  could  be  more  ra- 
tional or  simple  than  this  procedure,  adopted  by  Louis,  in  any  case  of 
an  open  wound,  where  the  fragments  could  be  easily  reached ;  but  the 
younger  Cline  was  the  first,  in  the  year  1814,  to  put  into  practice  the 
more  ancient  suggestion  of  Paulus  ^gineta,  namely,  to  attempt  the 
removal  of  the  fragments  in  a  case  of  simple  fracture.  He  made  an 
incision  upon  the  depressed  bone  as  the  patient  was  lying  upon  his 
face,  raised  the  muscles  covering  the  spinal  arch,  applied  a  small 
trephine  to  the  arch,  and  cut  it  through  on  each  side,  so  as  to  remove 
the  spinous  process,  and  the  arch  of  the  bone  which  pressed  upon  the 
spinal  marrow.  This  patient  died  on  the  4th  day.  Mr.  Oldknow  re- 
peated this  operation  in  1819  in  a  case  of  fracture  of  the  arch  of  the 
sixth  vertebra.  The  patient  died  on  the  7th  day.  In  1822,  Mr.  Tyrrell 
operated  at  St.  Thomas  Hospital  on  a  man  who  had  just  been  admitted 
with  a  fracture  through  the  arches  of  the  ninth  and  tenth  vertebrte. 
The  operation  was  accomplished  with  considerable  difficulty,  and  re- 
sulted in  only  a  partial  return  of  sensibility.  He  died  on  the  twelfth 
day.^  In  1827,  Tyrrell  operated  a  second  time,  and  death  resulted  on 
the  fifth  day.  On  the  30th  of  August,  1824,  Dr.  J.  Ehea  Barton,  of 
Philadelphia,  operated  upon  a  man  who  had  been  received  into  the 
Pennsylvania  Hospital  twelve  days  before,  with  a  fracture  of  the  arch 
of  the  seventh  dorsal  vertebra,  and  the  lower  part  of  whose  body  was 
at  the  time  completely  paralyzed.  On  removing  the  spinous  process, 
it  was  discovered  that  the  seventh  and  eighth  dorsal  vertebrae  were 
dislocated  upon  each  other.  No  immediate  relief  was  afforded  by  the 
operation,  but  sensibility  began  to  return  in  the  lower  extremities 
after  about  forty-eight  hours.  On  the  third  day  he  was  attacked  with 
a  violent  chill,  and  death  took  place  twelve  hours  after.  The  dissec- 
tion showed  about  half  a  gallon  of  blood  in  the  posterior  mediastinum, 
and  bloody  effusions  existed  along  the  whole  length  of  the  spinal  canal. ^ 
Dr.  Potter,  of  New  York,  who  operated  three  months  after  the  receipt 
of  the  injury,  lost  his  patient  on  the  eighteenth  day.^  The  patient 
whom  Laugier  trephined  at  the  base  of  the  spinous  process  of  the 
ninth  dorsal  vertebra,  died  on  the  fourth  day.  Chelius  says  that  the 
operation  has  been  repeated  unsuccessfully  by  Wickham,  Attenburrow, 
and  Holscher.'* 

February  5th,  1834,  Dr.  David  L.  Eogers,  of  New  York,  operated 
upon  a  man  who  had  fallen  two  days  before,  breaking  the  arch  of  the 
first  lumbar  vertebra,  and  forcing  the  spinous  process  upon  the  cord. 

'  Sir  A.  Cooper,  op.  cit.,  pp.  478—80. 

2  Barton,  Godman's  ed.  of  Sir  A.  Cooper  on  Disloc,  &c.,  p.  421. 

*  Potter,  Malgaigne,  translated,  note  by  Packard,  p.  344. 

*  Chelius's  Surgery,  Amer.  ed.,  vol.  i.  p.  590. 


154  FEACTURES  OF  THE  VERTEBRA. 

In  the  first  steps  of  the  operation  several  fragments  of  bone  were  re- 
moved which  had  been  broken  from  the  spinous  process,  and  only 
those  portions  of  the  arch  remained  which  were  attached  to  the  oblique 
processes.  An  effort  was  made  to  separate  these  processes  by  the 
knife,  but  this  was  found  to  be  impossible;  and  an  attempt  to  use 
Hey's  saw  caused  great  pain  accompanied  with  convulsive  actions  of 
the  muscles  of  the  back.  Having  finally  made  the  bone  fast  by  the 
aid  of  a  double  hook  and  elevator,  the  saw  was  again  applied  success- 
fully on  one  side.  The  opposite  side  was  also  at  length  removed  at 
the  articulations  of  the  oblique  processes  by  the  cautious  use  of  the 
knife  and  by  tractions.  About  two  inches  of  the  spinal  cord  was  now 
exposed,  covered  with  coagulated  blood.  The  cord  itself  did  not  seem 
to  be  injured.  In  about  fifteen  minutes  after  the  operation,  this  patient 
expressed  himself  as  being  much  relieved  ;  sensibility  returned  to  his 
lower  extremities ;  respiration  became  easy,  and  with  the  assistance  of 
an  anodyne  he  slept  for  several  hours.  Subsequently  he  became 
worse,  and  on  the  eighth  day  he  died ;  when  the  autopsy  revealed  a 
fracture  of  the  body  of  the  vertebra  from  which  the  spinous  process 
and  arch  had  been  removed,  but  no  displacement  of  the  fragments.^ 

These  are  all  of  the  cases  of  which  we  have  any  very  accurate  in- 
formation in  which  this  operation  has  been  made,  and  they  have  all 
terminated  fatally  in  a  very  few  days.  The  case  reported  by  Alban  Gr. 
Smith,  of  Kentucky,  is  not  related  in  such  a  manner  as  to  enable  us 
to  make  use  of  it  safely,  nor  is  it  stated  how  long  the  patient  survived 
the  operation ;  Gibson  says  it  gave  no  permanent  relief.  The  exam- 
ple mentioned  by  an  English  writer  is  equally  unreliable,  inasmuch 
as  it  is  given  only  upon  rumor,  and  but  a  "  few  months"  had  elapsed 
since  the  operation  was  performed.  It  was  said  to  have  been  made  in 
the  year  1838,  by  a  surgeon  of  the  name  of  Edwards,  in  South  Wales  ; 
and  it  was  affirmed  that  the  compression  was  relieved  and  that  the 
patient  "  did  well."^  So  unique  a  case  would  certainly  have  found 
before  this  an  ample  confirmation. 

Experience,  then,  seems  to  have  sufficiently  shown  that  we  have  no 
right  to  expect  anything  from  this  surgical  expedient;  and  notwith- 
standing the  strong  hope  expressed  by  Sir  Astley,  that  Mr.  Cline's 
operation  might  hereafter  prove  a  valuable  resource,  and  contrary  to 
the  conclusions  which  we  in  common  with  many  other  surgeons  had 
drawn  from  the  anatomical  relations  of  these  parts,  we  are  compelled 
reluctantly  to  declare  that  the  expedient  is  no  longer  worthy  of  a  trial. 
To  the  same  conclusion  also  many  of  the  most  distinguished  surgeons 
have  arrived ;  among  whom  we  may  mention,  as  especially  entitled  to 
confidence,  Brodie,  Liston,  Malgaigne,  and  Gibson. 

What  more  can  be  said  of  the  attempt  to  raise  the  depressed  bone 
by  seizing  the  spinous  process  with  the  fingers,  or  with  a  pair  of  strong 
hooked  forceps  passed  through  the  skin,  or  finally  if  this  cannot  be 
done,  by  laying  bare  both  sides  of  the  process  and  seizing  upon  it 
with  a  pair  of  firm  tenacula?     This  is  the  alternative  presented  to 

'  Rogers,  Amer.  Journ.  Med.  Sci.,  May,  1835,  vol.  xvi.  p.  93. 
2  Edwards,  British  and  Foreign  Med.  Rev.,  1838,  p.  162. 


FEACTURES  OF  THE  BODIES  OF  THE  VERTEBRA,    155 

Malgaigne,  and  which  he  ventures  to  recommend  as  deserving  a  trial. 
In  the  absence,  however,  of  any  testimony  in  its  favor,  beyond  the 
mere  rational  argument  adduced  by  this  distinguished  writer,  we  must 
waive  any  farther  consideration  of  the  subject;  only  expressing  our 
well-established  conviction  that  it  will  be  found,  after  a  fair  trial,  as 
useless  and  as  inexpedient  as  the  more  severe  operation  of  Cline. 

As  to  the  therapeutical  treatment  of  the  various  symptoms  belong- 
ing to  this  accident,  and  in  relation  to  the  prognosis,  the  remarks 
which  we  shall  make  will  be  found  equally  applicable  to  fractures  of 
the  bodies  of  the  vertebrae,  and  we  shall  reserve  the  consideration  of 
these  topics  for  the  following  section. 


§  4.  Fractures  op  the  Bodies  of  the  Vertebra. 

The  same  causes  which  produce  fractures  of  the  arches  produce  also 
fractures  of  the  bodies  of  the  vertebrae,  that  is,  blows  received  directly 
upon  the  extremities  of  the  spinous  processes ;  but  in  these  cases  the 
arches  are  generally  broken  at  the  same  time. 

In  other  cases  the  bodies  of  the  vertebra  are  broken  by  falls  upon 
the  top  of  the  head,  by  which  the  vertebrae  are  not  only  driven  forci- 
bly together,  but  often  doubled  forwards  upon  each  other;  or  the  patient 
may  have  alighted  upon  his  feet  or  upon  his  sacrum. 

Eeveillon  has  reported  a  case  of  fracture  of  the  fifth  cervical  verte- 
bra from  muscular  action,  which  occurred  in  diving.  The  man  was 
taken  out  of  the  water  unconscious,  and  died  in  a  few  hours,  having 
declared  before  death  that  his  head  did  not  strike  the  bottom,  although 
he  had  jumped  from  a  height  of  seven  or  eight  feet,  and  the  water  was 
only  three  feet  deep.^  The  statement  of  the  sufferer  under  such  cir- 
cumstances could  not  really  possess  much  value,  and  we  think  we  see 
good  reasons  to  suppose  that  he  was  mistaken.  South  also  relates  a 
case  of  fracture  of  the  fourth  and  fifth  cervical  vertebrae  occasioned 
by  diving,  in  which  it  was  supposed  that  the  fracture  was  caused  by 
the  concussion  of  the  head  upon  the  water.^ 

Malgaigne  says  the  spine  bends  at  three  principal  points;  comprised, 
the  first  between  the  third  and  seventh  cervical  vertebrae,  the  second 
between  the  eleventh  dorsal  and  second  lumbar,  the  third  between  the 
fourth  lumbar  and  the  sacrum;  and  that  a  majority  of  the  fractures  of 
the  vertebrae  occur  at  these  points  of  flexion.  He  makes  an  argument 
from  this  also  that  these  fractures  "  are  generally  the  result  of  counter- 
strokes  as  the  effect  of  forcible  flexion  of  the  column  either  forwards 
or  backwards."  Malgaigne  observes  moreover  that  dislocations  follow 
the  same  rule. 

The  direction  of  the  line  of  fracture  varies  greatly  in  the  different 
examples  which  we  have  seen ;  some  are  crushed,  and  more  or  less 
comminuted.  In  some  cases  a  narrow  piece  is  chipped  from  the  mar- 
gin, others  are  broken  transversely,  and  others  obliquely.     In  oblique 

'  Reveillon,  Chelius's  Surg.,  note  by  South,  vol.  i.  p.  584. 
2  South,  ibid.,  p.  583. 


156 


FEACTUEES    OF    THE    VEETEBE^. 


Fig.  33. 


fractures  the  line  of  the  fracture  is  generally  from  behind  forwards 
and  from  above  downwards.  Malgaigne  thinks  that  a  crushing  or 
comminution  can  only  occur  from  a  forcible  flexion  forwards ;  but  I 
have  seen  at  least  one  example  in  which  this  was  not  the  fact;  the 
patient  having  fallen  so  as  to  strike  with  the  back  of  his  neck  upon 
an  iron  bar.  This  was  the  case  of  the  sailor,  to  which  I  shall  again 
refer  more  particularly. 

The  upper  fragment  is  almost  always  that  which  suffers  displace- 
ment ;  sometimes  being  simply  driven  downwards  and  thus  made  to 
penetrate  more  or  less  the  lower  fragment ;  at  other  times,  as  in  cer- 
tain transverse  fractures,  it  is  only  displaced 
forwards,  and  in  still  other  examples,  where 
the  fracture  is  oblique,  the  upper  fragment  is 
displaced  both  downwards  and  forwards. 

In  the  first  and  last  of  these  examples  the 
spine  becomes  bent  forwards  at  the  point  of 
fracture,  producing  an  angle  of  which  the 
most  salient  point  posteriorly  is  represented 
by  the  extremity  of  the  spinous  process  be- 
longing to  the  broken  vertebra;  in  the  second 
example  the  spinous  process  of  the  broken 
vertebra  is  depressed,  and  the  process  of  the 
vertebra  next  below  is  relatively  prominent. 

In  a  pretty  large  proportion  of  cases  also 
the  fracture  of  the  body  of  the  vertebra  is 
complicated,  as  we  have  already  stated,  with  a 
fracture  of  the  arches,  in  some  instances  with 
a  fracture  of  the  oblique  processes  and  with  a 
dislocation. 
Symptoms, — Severe  pain  at  the  seat  of  fracture,  felt  especially  when 
the  part  is  touched  or  the  body  is  moved,  tenderness,  swelling,  ecchy- 
mosis,  occasionally  crepitus,  a  slight  angular  distortion  of  the  spine,  or 
simply  a  trifling  irregularity  in  the  position  of  the  processes,  and 
paralysis  of  all  the  parts  whose  nerves  take  their  origin  below  the 
fracture,  are  the  usual  signs  of  this  accident. 

The  paralysis  may  be  due  to  the  mere  pressure  of  the  displaced 
fragments,  but  it  is  much  more  often  due  to  a  severe  and  irreparable 
lesion  of  the  cord  itself  I  have  in  one  instance  seen  the  cord  almost 
completely  separated  at  the  point  of  fracture  although  the  displace- 
ment of  the  fragments  was  inconsiderable. 

Accompanying  the  paralysis  of  the  bladder,  there  has  been  generally 
observed  an  alkaline  state  of  the  urine,  and  subacute  inflammation  of 
the  coats  of  the  bladder.  Priapism  is  present  in  a  certain  proportion 
of  cases. 

Those  who  die  immediately  seem  to  be  asphyxiated;  while  those 
who  die  later  seem  to  wear  out  from  general  irritation,  this  condition 
being  frequently  accompanied  with  an  obstinate  diarrhoea  and  vomit- 
ing.    A  few  become  comatose  before  death. 

It  will  be  seen,  moreover,  that  a  certain  proportion  finally  recover ; 


Oblique  fracture  of  the  body 
of  a  vertebra. 


FRACTURES    OF    THE    BODIES    OF    THE    VERTEBRAE.  157 

but  scarcely  ever  are  all  the  functions  of  the  limbs  and  of  the  body 
completely  restored. 

We  shall  render  this  part  of  our  description  of  these  accidents  more 
intelligible  if  we  regard  them  as  they  occur  in  the  various  portions  of 
the  spinal  column,  since  the  symptoms,  prognosis,  and  treatment,  have 
reference  mainly  to  the  point  at  which  the  fracture  has  occurred. 

1.  Fractures  of  the  Bodies  of  the  Lumbar  Vertebrae. 

The  nerves  which  emerge  from  the  intervertebral  foramina  below 
the  fourth  and  fifth  lumbar  vertebrae,  join  with  the  sacral  nerves  to 
form  a  plexus,  which  supplies  the  sphincter  and  levator  ani,  the  peri- 
neal muscles,  the  detrusor  and  accelerator  urinse,  the  urethra,  glans 
penis,  and  a  great  proportion  of  the  lower  extremities. 

A  fracture,  therefore,  of  the  third,  fourth  or  fifth  lumbar  vertebra, 
produces  more  or  less  complete  paralysis  of  the  lower  extremities, 
paralysis  of  the  bladder,  indicated  by  retention  of  the  urine,  and 
paralysis  of  the  rectum,  the  latter  being  accompanied  sometimes  by 
involuntary  discharges  from  the  bowels  and  at  other  times  by  constipa- 
tion. These  patients  generally  die  after  a  few  months  or  years  from 
a  general  nervous  irritation  with  consequent  exhaustion  of  the  system. 
The  following  case,  related  by  Sir  Benjamin  Brodie,  illustrates,  proba- 
bly, a  more  favorable  termination. 

A  boy  was  admitted  into  St.  George's  Hospital,  in  Sept.  1827,  with 
a  fracture  and  considerable  displacement  of  the  third  and  fourth 
lumbar  vertebrae,  the  displacement  being  sufficient  to  cause  a  manifest 
alteration  in  the  figure  of  his  spine.  His  lower  limbs  were  paralytic. 
An  attempt  was  made  to  restore  the  displaced  vertebrae,  but  it  was 
attended  with  only  partial  success.  At  the  end  of  a  month  he  had 
slight  involuntary  motions  of  the  lower  extremities,  and  at  the  same 
time  he  began  to  recover  the  power  of  using  them  voluntarily.  Three 
or  four  months  after  the  receipt  of  the  injury  he  left  the  hospital,  and 
the  history  of  his  case  was  interrupted  at  this  date.^ 

In  case  the  fracture  is  at  a  point  higher  up,  in  the  first  or  second 
lumbar  or  last  dorsal  vertebra,  the  whole  of  the  lumbar  nerves  are 
cut  off,  producing  a  more  complete  paralysis  of  the  lower  extremities, 
accompanied  with  the  same  paralysis  of  the  bladder  and  rectum.  Death 
also  ensues  at  a  somev/hat  earlier  period  and  frotn  the  same  causes. 

A  few  years  since  a  Mrs.  Squires,  of  Eochester,  N.  Y.,  was  shot  in 
her  back,  the  ball  lodging  in  the  body  of  one  of  the  lumbar  vertebrae, 
from  which  it  was  found  impossible  to  extract  it.  Her  lower  extremi- 
ties were  completely  paralyzed,  and  also  the  sphincters  of  her  bladder 
and  rectum ;  a  pin  thrust  into  the  body  at  any  point  below  the  middle 
of  the  abdomen  was  not  felt.  She  survived  the  accident  several 
months,  and  died  at  last  covered  with  bed  sores  and  exhausted  with 
pain  and  watchfulness. 

On  the  11th  of  Oct.,  1851,  Alfred  McCarty,  aet.  47,  residing  at  Fort 
Erie,  C.  W.,  was  struck  upon  the  back  with  a  falling  timber  weighing 

'  Brodie,  Sir  Ast.  Cooper  on  Disloc,  op.  cit.,  p.  471. 


158 


FRACTUEES  OF  THE  VEETEBRiE. 


half  a  ton  or  more,  fracturing  four  ribs  upon  the  left  side,  and  probably 
the  lower  dorsal  vertebrae.  The  right  leg  was  also  badly  broken  at  the 
same  time.  He  was  taken  up  insensible,  but  soon  recovered  his  con- 
sciousness, when  it  was  ascertained  that  the  lower  half  of  his  body 
was  paralyzed.  I  saw  him  a  few  days  after  the  accident  in  consulta- 
tion with  Dr.  Cronyn,  a  very  intelligent  surgeon  residing  at  Fort  Erie. 
We  agreed  that  the  treatment  ought  to  be  sustaining  and  expectant 
mainly.  Constantly  during  the  first  three  or  four  months,  and  occa- 
sionally for  some  time  longer,  the  urine  had  to  be  drawn  oft'  with  a 
catheter.  A  large  bed-sore  soon  formed  upon  his  sacrum.  There  was, 
however,  in  the  main,  a  steady  improvement,  so  that  in  April,  six 
months  after  the  accident,  he  was  able  to  sit  with  his  back  supported ; 
the  bed-sore  had  healed  ;  sensation  had  in  a  great  measure  returned  to 
his  lower  extremities,  but  motion  only  slightly ;  he  had  gained  flesh 
and  strength.  He  now  only  rarely  required  the  use  of  the  catheter, 
but  as  soon  as  the  desire  to  urinate  was  experienced  he  was  compelled 
to  discharge  it,  having  lost  the  power  of  retention.  It  was  the  same 
with  his  fecal  discharges.  The  urine  was  alkaline.  About  this  time 
he  began  to  experience  a  stifi'ness  in  one  of  his  hands,  inability  to 
close  the  fingers  upon  the  palm,  and  slight  uneasiness  in  the  neck. 
Gradually  both  arms  became  completely  paralyzed,  vomiting  and 
purging  supervened,  and  after  repeated  attacks  in  the  last  month  of 
his  life  of  laryngo-tracheal  constriction,  on  the  20th  of  Sept.,  1852,  he 
sank  into  a  state  of  complete  paralysis  and  insensibility,  and  died, 

A  .patient  in  Guy's  Hospital,  under  Mr.  Key,  with  a  fracture  of  the 
first  lumbar  vertebra,  lived  one  year  and  two  days.  On  examination 
after  death  it  was  ascertained  that  bony  union 
had  occurred  between  the  fragments,  and  that 
the  spinal  marrow  was  completely  separated  at 
the  point  of  fracture.' 

Mr.  Harrold  relates  a  case  of  fracture  of  the 
first  and  second  lumbar  vertebras,  in  which  the 
patient  survived  the  accident  one  year  lacking 
nine  days ;  death  having  resulted  finally  from 
a  sore  on  the  tuberosity  of  the  ischium  and 
disease  of  the  bone.  After  death  it  was  ascer- 
tained that  the  fracture  had  united  by  ossific 
matter,  and  that  the  spinal  marrow  was  almost 
completely  cut  in  two,  the  divided  extremities 
being  enlarged  and  separated  nearly  an  inch 
from  each  other.  ^ 

Dr.  Thompson,  of  Goshen,  N,  Y.,  has  seen  a 

partial  recovery  after  a  fracture  of  the  third  or 

fourth  vertebra  of  the  loins.     The  patient  fell 

from  the  roof  of  a  house  striking  first  upon  his 

feet  and  then  upon  his  buttocks.     This  occurred  in  Oct.  1853.     The 

usual  signs  of  a  fracture  were  present,  such  as  paralysis,  &c.     A  bed- 


Fig.  34. 


Key's  case  of  fracture  of  the 
first  lumbar  vertebra. 


'  Key,  A.  Cooper  on  Disloc,  &c.,  op.  cit.,  p.  467. 
'^  Harrold,  A.  Cooper,  op.  cit.,  p.  464, 


FEACTUKES    OF    THE    BODIES    OF    THE    VEETEBR^.         159 

sore  formed  above  tlie  top  of  the  sacrum,  and  a  piece  of  bone  exfoli- 
ated which  seemed  to  belong  to  the  last  lumbar  vertebra.  He  was 
confined  to  his  bed  seven  months.  After  eighteen  months  he  began 
to  use  crutches.  At  the  end  of  about  three  years  all  improvement 
ceased ;  at  which  time  he  could  not  quite  stand  alone,  yet  with  the 
aid  of  apparatus  he  was  able  to  get  about  the  country  and  peddle 
books,  prints,  &c.     This  was  also  his  condition  one  year  later.^ 

2.  Fractures  of  the  Bodies  of  the  Dorsal  Vertehrae. 

In  these  examples,  the  same  organs  are  paralyzed  as  in  the  fractures 
lower  down,  in  addition  to  which  there  is  generally  considerable  dis- 
turbance of  the  functions  of  respiration,  irregular  action  of  the  heart, 
indigestion  accompanied  with  a  tympanitic  state  of  the  bowels. 

Dupuytren,  who  reports  several  examples  of  fractures  of  the  dorsal 
vertebras,  has  not  taken  the  pains  to  record  the  length  of  time  they 
survived  the  accident  except  in  two  instances,  both  of  which  were 
fractures  of  the  eleventh  vertebra.  One  died  of  suffocation  on  the 
tenth  day,  and  the  other  on  the  thirty-second.  In  Sir  Astley  Cooper's 
cases,  mention  is  made  of  a  fracture  of  the  twelfth  dorsal  vertebra, 
which  the  patient  survived  fifty-two  days,  one  of  the  tenth  dorsal, 
which  terminated  fatall}^  in  six  days,  and  another  of  the  ninth  dorsal, 
which  did  not  result  in  death  until  after  nine  weeks. 

In  1853  Dr.  Parkman  presented  to  the  Boston  Society  for  Medical 
Improvement  a  specimen  of  fracture  of  the  fifth  dorsal  vertebra,  the 
bodies  of  the  third  and  fourth  being  also  displaced  forwards,  in  which 
position  they  had  become  firmly  ossified.  The  spinal  cord  had  been 
completely  separated,  yet  the  patient  survived  the  accident  two 
months.^ 

Dupuytren  has  related  also  two  examples  of  fractures,  one  of  the 
tenth  and  the  other  of  the  last  dorsal  vertebra,  from  which  the  patients 
completely  recovered  after  from  two  to  four  months'  confinement.^  A 
similar  case  is  related  by  Lente,  of  New  York.  Barney  McGuire, 
having  fallen  a  distance  of  twelve  or  fifteen  feet  upon  his  back,  was 
found  with  nearly  complete  paralysis  of  his  lower  extremities,  and  of 
his  bladder.  Swelling  existed  over  the  lower  dorsal  vertebrae,  and 
this  point  was  very  tender.  Subsequentl}^,  when  the  swelling  subsided, 
the  prominence  of  the  spinous  processes  of  the  tenth  and  eleventh 
dorsal  vertebrte  put  the  question  of  a  fracture  beyond  doubt.  Gradu- 
ally under  the  use  of  cups,  strychnia,  mineral  acids,  laxatives,  buchu, 
and  electricity,  his  symptoms  improved.  In  six  months  he  was  able 
to  walk  about  the  streets,  and  four  years  after  the  accident  he  was 
employed  in  a  foundry  under  regular  wages,  being  able  to  stand  fif- 
teen or  twenty  minutes  at  a  time,  and  to  walk  half  a  mile  without 
resting.  At  this  time  there  remained  no  tenderness  in  the  spine,  but 
the  projection  of  the  process  was  the  same  as  at  first.'^ 

'  Thompson,  Amer.  Journ.  Med.  Sci.,  Oct.  1857.     Lente's  paper.  ' 

2  Parkman,  New  York  .Journ.  Med.,  March,  1853,  p.  286. 

3  Dupuytren,  op.  cit.,  pp.  356-7. 

^  Lente,  Amer.  Journ.  Med.  Sci.,  Oct.  1857,  p.  361. 


160  FRACTURES  OF  THE  VERTEBRA. 


3.  Fractures  of  the  Bodies  of  the  five  lower  Cervical  Vertebrse. 

We  shall  now  have  added  to  the  symptoms  already  enumerated, 
paralysis  of  the  upper  extremities,  greater  embarrassment  of  the  res- 
piration, and  more  complete  loss  of  sensation  and  volition  in  the  lower 
part  of  the  body.  In  general  also  the  eyes  and  face  look  congested, 
owing  to  the  imperfect  arterialization  of  the  blood,  and  death  is  more 
speedy  and  inevitable. 

In  eight  recorded  examples  of  fractures  of  the  five  lower  cervical 
vertebree,  one  died  within  twenty-four  hours,  four  in  about  forty-eight 
hours,  one  in  eleven  days,  one  lived  fifteen  weeks  and  six  days,  and 
one  about  four  months.  The  most  common  period  of  death  seems 
therefore  to  be  about  forty-eight  hours  after  the  receipt  of  the  injury. 

The  example  of  the  patient  who  survived  the  accident  fifteen  weeks 
and  six  days,  is  recorded  by  Mr.  Greenwood,  of  England.  A  woman, 
Mary  Vincent,  £et.  47,  was  injured  by  a  blow  on  the  back  of  her  neck, 
but  she  was  not  seen  by  Mr.  Greenwood  until  after  eleven  days,  at 
which  time  she  was  breathing  with  difficulty,  occasioned  by  paralysis 
of  the  intercostal  muscles,  respiration  being  carried  on  by  the  dia- 
phragm and  abdominal  muscles  alone.  This  was  the  extent  of  the 
paralysis.  There  seemed  to  be  a  depression  opposite  the  fourth  and 
fifth  cervical  vertebrse,  and  pressure  at  this  point  occasioned  universal 
paralysis,  as  did  also  the  action  of  coughing  and  sneezing.  About 
three  weeks  after  the  accident,  she  attempted  for  the  first  time  to  move, 
in  order  to  have  her  clothes  changed,  when  she  was  immediately  seized 
with  paralysis  in  the  right  arm  and  hand.  After  this  she  lost  her 
appetite,  had  frequent  attacks  of  purging,  and  thus  she  gradually  wore 
out.' 

The  patient  who  survived  about  four  months,  was  admitted  into 
Hotel  Dieu,  under  the  care  of  Dupuytren,  in  1825,  on  account  of  a 
fracture  of  the  fourth  cervical  vertebra,  caused  by  a  fall  on  the  back 
of  his  neck,  and  suffering  under  paralysis  of  the  bladder  and  extremi- 
ties. After  two  months  and  a  half  of  entire  rest,  he  was  convalescent 
and  quitted  the  hospital,  with  only  slight  weakness  in  his  left  leg,  and 
with  his  head  a  little  bowed  forwards.  In  returning  from  a  long  walk 
he  fell  paralyzed,  and  remained  in  the  open  air  all  night.  From  this 
time  he  continued  to  fail,  and  died  thirty-four  days  after  the  second 
fall.  On  examination  after  death,  the  body  of  the  vertebra  was 
found  to  be  broken,  and  also  the  processes  of  the  fifth,  allowing  the 
fourth  to  slip  forwards  and  compress  the  cord.  A  true  callus  existed 
in  front  of  these  bones,  which  looked  as  if  recently  broken.  The  cord 
itself  exhibited  an  annular  constriction,  which  Dupuytren  conceived 
to  be  the  seat  of  the  original  lesion  narrowed  by  cicatrization.^ 

The  following  example  furnishes  a  fair  illustration  of  the  usual 
phenomena  which  accompany  fractures  of  third  or  fourth  cervical 
vertebra. 

'  Greenwood,  Sir  A.  Cooper  on  Disloc,  p.  472. 
^  Dupuytren,  op.  cit.,  p.  358. 


FEACTUEES    OF    THE    BODIES    OF    THE    VEETEBE^.         161 

On  the  25th  of  July,  1857,  a  sailor  fell  backwards  from  the  wharf, 
striking  with  the  nape  of  his  neck  upon  a  bar  of  iron.  I  saw  him  on 
the  following  day  in  consultation  with  his  attending  physician,  Dr. 
Edwards,  of  this  city.  He  was  lying  upon  his  back  breathing  rapidly. 
His  lower  extremities  were  completely  paralyzed;  legs  and  feet  swollen 
and  purple;  right  arm  completely  paralyzed,  and  his  left  partially; 
from  a  point  below  the  line  of  the  second  rib,  there  was  no  sensation 
whatever ;  his  bowels  had  not  moved,  although  he  had  already  taken 
active  cathartics;  the  urine  had  been  drawn  with  a  catheter;  the  pulse 
was  slower  than  natural,  and  irregular.  He  was  constantly  vomiting. 
In  reply  to  questions,  he  said  that  he  felt  well,  articulating  distinctly 
and  with  a  good  voice.  His  eyes  and  face  were  somewhat  congested, 
but  with  this  exception  his  countenance  did  not  betray  the  least  phy- 
sical disturbance.  He  lived  in  this  condition  about  forty  hours,  only 
breathing  shorter  and  shorter,  and  his  consciousness  remaining  to  the 
last  moment. 

In  proceeding  to  examine  the  spine  a  few  hours  after  death,  and 
before  any  incision  was  made,  we  were  unable,  upon  the  most  minute 
examination,  to  detect  any  irregularity  of  the  processes  of  the  cervical 
vertebras,  or  any  crepitus,  but  on  dissecting  the  neck  we  found  that 
the  arches  of  the  third  and  fourth  vertebrse  were  broken,  and  the 
spinous  processes  slightly  depressed  upon  the  cord.  The  bodies  of 
the  corresponding  vertebrae  were  comminuted  and  the  vertebrge  above 
were  driven  down  upon  them,  carrying  the  processes  in  the  same 
direction.  The  theca  and  the  spinal  marrow  were  almost  completely 
severed  upon  a  level  with  the  fourth  vertebra. 

About  one  year  since,  a  man  was  thrown  backwards  suddenly  from 
the  back  end  of  a  wagon,  alighting  upon  the  top  of  his  head.  Dr. 
Mixer,  of  this  city,  having  requested  me  to  see  this  patient  with  him, 
I  found  the  symptoms  almost  an  exact  counterpart  of  those  which 
belonged  to  the  case  which  I  have  just  described,  except  that  a  crepitus 
and  a  mobility  of  the  fragments  could  be  distinctly  felt  in  the  upper 
and  back  part  of  his  neck.  His  death  occurred  in  very  much  the 
same  manner  after  about  forty-eight  hours.  No  autopsy  was  allowed. 
We  noticed  in  this  case,  also,  that  whenever  he  was  turned  over  upon 
his  face  respiration  almost  entirely  ceased,  but  it  was  immediately 
restored  by  laying  him  again  upon  his  back. 

Dupuytren,  Sir  Astley  Cooper,  South,  and  other  surgeons,  have 
related  cases  simulating  fracture,  but  which  proved  to  be  strains  of 
the  ligaments  uniting  the  cervical  vertebrae,  accompanied  with  more 
or  less  injury  to  the  spinal  marrow.  In  one  instance,  I  have  met  with 
what  has  seemed  to  be  a  strain  of  the  ligaments  and  muscles  of  the 
neck,  but  which  presented  no  symptoms  of  serious  injury  to  the  spinal 
marrow. 

John  Neuman,  of  Canada  West,  aet.  25,  fell  head  foremost  from  a 
height  of  fourteen  feet,  striking  upon  the  top  of  his  head.  He  was 
taken  up  insensible,  and  remained  in  this  condition  six  hours.  When 
consciousness  returned,  his  head  was  very  much  drawn  backwards, 
and  it  was  impossible  to  move  it  from  this  position.  There  was  no 
lack  of  sensibility  or  of  the  power  of  motion  in  his  limbs,  and  all  the 
11 


162  FEACTUEES    OF    THE    VEETEBE^. 

functioDS  of  his  body  were  in  their  natural  state;  but  lie  has  suffered 
with  occasional  severe  pains  in  his  arms  ever  since.  The  accident 
happened  on  the  twenty-fourth  of  November,  1857,  and  he  called  upon 
me  eight  months  after.  His  head  was  then  forcibly  bent  forwards 
instead  of  backwards,  into  which  position  it  had  gradually  changed. 
In  the  morning  he  generally  was  able  to  erect  his  head  completely, 
but  after  a  few  hours  it  was  constantly  drawn  forwards,  as  when  I  saw 
him.  There  was  no  tenderness  or  irregularity  over  the  cervical  verte- 
brge,  and  he  was  so  well  as  to  be  regularly  employed  as  a  day  laborer. 

Sir  Astley  Cooper  has  collected  four  examples  of  what  he  terms 
"  concussion  of  the  spinal  marrow,"  all  of  which  recovered  after  periods 
ranging  from  a  few  weeks  to  many  months ;  but  in  only  one  case  is  it 
stated  that  the  recovery  was  complete.''  Boyer  also  enumerates  three 
cases  of  concussion  which  came  under  his  own  observation,  all  of 
which  terminated  fatally  in  a  short  time.  In  the  first  example  men- 
tioned by  Boyer,  the  autopsy  disclosed  neither  lesion  nor  effusion  of 
any  kind  ;  in  the  second  case,  it  does  not  appear  that  any  autopsy 
was  made.  The  third  is  related  as  follows :  "  A  builder  fell  from  a 
height  of  fourteen  feet,  and  remained  for  some  time  senseless;  and,  on 
recovering  from  that  situation,  found  that  he  had  lost  the  use  of  his 
inferior  extremities.  He  had  at  the  same  time  a  retention  of  urine,  an 
involuntary  discharge  of  the  feces,  and  some  disorder  in  the  function 
of  respiration.  Death  followed  on  the  twelfth  day  after  the  accident. 
The  body  was  opened,  and  the  vertebral  canal  was  found  to  contain  a 
sanguineous  serum,  the  quantity  of  which  was  sufficient  to  fill  a  little 
more  than  its  lower  half  "^ 

Treatment. — In  a  few  instances,  I  have  noticed  among  the  recorded 
examples  of  fractures  of  the  bodies  of  the  vertebrae,  that  surgeons 
have  made  some  slight  attempt  to  reduce  the  fracture,  or  rather  to 
rectify  the  spinal  distortion,  generally  by  the  application  of  moderate 
extension  to  the  limbs,  and  by  laying  the  patient  horizontally  upon  a 
hard  mattress.  But  I  have  not  been  able  to  discover  that  in  any  case 
the  patients  have  derived  benefit  from  the  attempt,  although  it  has 
been  said  occasionally  by  the  gentlemen  making  the  report,  that  the 
deformity  was  slightly  diminished.  Nor  am  I  aware  that  in  any 
instance  the  patient  has  suffered  any  damage  from  the  attempt;  at 
least  the  reporter  has  in  no  case  thought  it  necessary  to  make  this 
observation.  I  am  confident,  however,  that  such  manipulation  can 
never  serve  any  useful  purpose;  and  I  very  much  fear  that  it  has 
been  frequently  a  source  of  mischief  Although  in  cases  so  generally 
fatal,  it  might  be  very  difficult  to  estimate  with  much  accuracy  the 
amount  of  injury  done.  If  by  any  possibility  the  fragments  could  be 
replaced,  I  know  of  no  means  by  which  they  could  be  kept  in  place ; 
and  in  truth  we  are  much  more  likely  to  increase  the  penetration  of 
the  spinal  cord  and  the  general  disturbance,  than  to  diminish  it  by 
extension  or  pressure.  Moreover,  it  inflicts  upon  the  unfortunate 
sufferer  great  pain,  and  for  this  reason,  unless  it  can  be  shown  to  have 

'  A.  Cooper,  op.  cit.,  p.  454. 

'^  Boyer,  Lectures  on  Diseases  of  the  Bones,  Amer.  ed.,  1805,  p.  55. 


FRACTURES    OF    THE    BODIES    OF    THE    VERTEBRA.         163 

heretofore   accomplislied   some   good   purpose,  it   ought   to  be  dis- 
couraged. 

When  treating  of  fractures  of  the  arches  of  the  vertebrjB,  I  took 
occasion  to  call  attention  to  Mr.  Cline's  operation,  occasionally  recom- 
mended and  practised  in  such  cases.  I  was  not  ignorant,  however, 
that  Mr.  Cline  and  several  other  of  the  advocates  of  this  operation 
had  recommended  it  especially  for  fractures  of  the  bodies  of  the 
vertebrae  when  accompanied  with  displacement.  Even  Malgaigne 
has  preferred  to  consider  the  merits  of  this  operation  in  its  relations 
to  these  latter  fractures ;  but  while  I  am  prepared  to  admit  the  pro- 
priety of  an  argument  as  to  the  value  of  Cline's  operation  considered 
in  reference  to  fractures  of  the  arches,  I  cannot  admit  its  propriety  in 
reference  to  fractures  of  the  bodies  of  the  vertebrae.  The  proposition 
appears  to  me  too  absurd  to  be  entertained  for  a  moment. 

The  treatment,  then,  ought  to  be,  in  a  great  measure,  expectant.. 
The  patient  should  be  laid  in  such  a  position  as  he  finds  most  com- 
fortable, and,  as  far  as  possible,  the  spine  should  be  kept  at  rest,  since 
the  most  trivial  disturbance  of  the  fragments  and  even  that  whicb 
may  cause  no  pain  to  the  patient,  is  liable  to  increase  the  injury  ta 
the  spine,  and  prevent  the  formation  of  a  bony  callus.  Especially 
ought  the  surgeon  to  be  careful  while  making  the  examination,  not  to- 
turn  the  patient  upon  his  face,  in  which  position  the  spine  loses  its 
support  and  a  fatal  pressure  may  be  produced.  The  urine  should  be- 
drawn  very  soon  after  the  accident,  and  at  least  twice  daily,  for  the 
next  few  weeks.  Indeed,  it  is  a  better  rule  to  draw  the  urine  as  often 
as  its  accumulation  becomes  a  source  of  inconvenience,  or  whenever 
the  bladder  fills,  which  will  in  some  cases  be  as  often  as  every  four  or 
six  hours.  It  is  especially  necessary  to  attend  to  these  urgent  de- 
mands of  the  patient  during  the  first  few  weeks,  when  the  paralysis 
is  most  complete  generally,  and  the  mucous  surface  of  the  bladder,, 
already  irritated  and  inflamed  by  the  excessively  alkaline  urine,  suffers, 
additional  injury  from  any  degree  of  painful  distension  of  its  walls. 
It  is  unnecessary  to  say  that  the  frequent  introduction  of  the  catheter 
may  itself  prove  a  source  of  irritation  unless  it  is  managed  carefully 
and  skilfully.  This  duty  ought  never  to  be  intrusted  to  an  inexpe- 
rienced operator. 

I  do  not  see  what  advantage  the  surgeon  can  expect  to  derive  from' 
the  administration  of  drastic  purgatives,  such  as  full  doses  of  jalap, 
castor  oil,  or  spirits  of  turpentine,  at  any  period.  If  in  the  first 
instance  the  bowels  are  so  completely  paralyzed  as  that  they  seem  to 
demand  such  violent  measures  to  arouse  them  to  action,  we  may  be 
quite  certain  that  the  spinal  cord  is  suffering  from  a  pressure,  or  from 
some  lesion  which  these  agents  have  no  power  to  remedy.  The  bowels 
may  possibly  be  made  to  act,  but  it  would  be  difficult  to  show  how 
this  is  to  relieve  the  suffering  cord.  So  far  from  affording  relief,  these 
measures  add  directly  to  the  nervous  irritation  and  prostration,  pro- 
voke vomiting  and  general  restlessness.  It  is  not  desirable,  we  think, 
to  obtain  a  movement  of  the  bowels  during  the  first  few  days  by  any 
means,  however  gentle.  The  effort  to  defecate,  and  the  consequent 
motion,  will  probably  do  much  more  harm  than  the  evacuation  can  do 


164  FEACTURES    OF    THE    VERTEBRiE. 

good ;  and  especially  for  the  same  reason  ought  we  to  avoid  putting 
into  the  stomach  anything  which  will  occasion  nausea  and  vomiting. 

After  the  lapse  of  a  few  days,  if  reasonable  hopes  begin  to  be  enter- 
tained of  a  recovery,  it  will  become  important  to  establish  regular  eva- 
cuations of  the  bowels,  either  by  a  judicious  management  of  the  diet,  by 
gentle  laxatives,  or  by  enemata.  At  a  still  later  period,  when  the  in- 
flammatory stage  is  past,  and  the  nerves  remain  inactive  or  paralyzed, 
nothing  could  be  more  rational  than  the  employment  of  strychnia  in 
doses  varying  from  the  one-twelfth  to  the  one-eighth  of  a  grain  three 
times  daily.  Nor  do  I  think,  that  any  single  remedy  has  more  often 
proved  useful  in  my  own  practice,  or  in  the  practice  of  other  surgeons 
with  whom  I  am  acquainted.  In  order,  however,  to  derive  benefit  from 
this  or  from  any  other  remedy,  it  must  be  continued  for  a  long  time  ; 
perhaps  for  a  year  or  more.  Electricity,  setons,  issues,  and  blisters  are 
no  doubt  also  sometimes  useful.  Care  must  be  taken  that  setons,  &c., 
do  not  produce  bed-sores.  Passive  motion  and  frictions,  good  fresh  air 
and  nourishing  diet,  become  at  last  essential  to  recovery. 

During  the  whole  course  of  the  treatment  great  attention  should  be 
paid  to  the  prevention  of  bed-sores,  by  supporting  all  of  those  parts 
of  the  body  upon  which  the  pressure  is  considerable.  For  this  pur- 
pose we  may  employ  circular  cushions,  air-cushions  and  water- cushions 
or  water-beds ;  but  with  the  utmost  diligence  they  cannot  generally  be 
wholly  prevented.  When  the  sores  have  formed  they  should  be  treated, 
if  sloughing,  with  yeast  poultices,  or  the  resin  ointment.  I  find  also 
the  resin  ointment  an  excellent  dressing  for  the  sores  after  the  sloughs 
have  separated.  In  case  the  surface  is  only  slightly  abraded,  simple 
cerate  forms  the  best  application. 


§  5.  Fractures  op  the  Axis. 

The  phrenic  nerve  is  derived  chiefly  from  the  third  and  fourth  cer- 
vical nerves.  If,  therefore,  the  second  cervical  vertebra  is  broken 
and  considerably  depressed  upon  the  spinal  cord,  respiration  ceases 
immediately,  and  the  patient  dies  at  once,  or  survives  only  a  few 
minutes.  In  such  examples  of  fracture  of  this  bone  as  have  not  been 
attended  with  these  results,  the  displacement  and  consequent  compres- 
sion, have  been  inconsiderable,  or  there  has  been  no  displacement  at  all. 

Mr.  Else,  of  St.  Thomas's  Hospital,  says  that  a  woman  in  the  vene- 
real ward,  and  who  was  then  under  a  mercurial  course,  while  sitting  in 
bed,  eating  her  dinner,  was  seen  to  fall  suddenly  forwards;  and  the 
patients,  hastening  to  her,  found  that  she  was  dead.  Upon  examina- 
tion of  her  body,  it  was  discovered  that  the  processus  dentatus  of  the 
axis  was  broken  off,  and  that  the  head  in  falling  forwards  had  driven 
the  process  backwards  upon  the  spinal  marrow  so  as  to  cause  her 
death.^ 

Sir  Astley  also  relates  the  case  of  a  man  who  was  shot  by  a  pistol 
through  the  neck,  breaking  and  driving  in  upon  the  spinal  marrow 

'  Else,  A.  Cooper  on  Disloc,  &c.,  op.  cit.,  p.  462. 


FRACTURES    OF    THE    AXIS.  165 

both  the  "lamina  and  the  transverse  process"  of  the  axis.    He  died 
on  the  fourth  day.^ 

Malgaigne  has  collected  three  cases  of  fracture  of  the  odontoid 
apophysis,  all  of  which  were  accompanied  with  a  displacement  of  the 
atlas.  The  first,  reported  by  Eichet,  died  on  the  seventeenth  day ; 
the  second,  reported  by  Palletta,  died  after  one  month  and  six  days ; 
and  the  third,  by  Costes,  lived  four  months  and  two  weeks. 

In  no  case  upon  record  has  the  patient  survived  this  accident  so 
long  as  in  the  case  reported  by  Bigelow,  and  published  by  Parker,  of 
New  York.     Says  Dr.  Parker — 

"  The  patient,  Mr.  G.  B.  Spencer,  was  a  man  forty  years  of  age,  a 
milkman  by  occupation,  of  medium  height,  nervo-sanguine  tempera- 
ment, of  active  business  habits,  and  capable  of  great  endurance.  His 
life  was  one  of  constant  excitement,  and  he  was  addicted  to  the  free 
use  of  liquors.  He  suffered,  however,  from  no  other  form  of  disease 
than  occasional  attacks  of  rheumatism,  for  which  he  was  accustomed 
to  take  remedies  of  his  own  prescribing,  which  were  generally  mer- 
curials followed  by  liberal  doses  of  iodide  of  potassium,  '  to  work  it 
all  out  of  the  system.' 

"On  the  12th  of  August,  1852,  while  driving  a  'fast  horse'  at  the 
top  of  his  speed  on  the  plank  road  near  Bush  wick,  L.  I.,  he  was  thrown 
violently  from  his  carriage  by  the  wheel  striking  against  the  toll-gate. 
He  alighted  upon  his  head  and  face  about  fifteen  feet  from  the  carriage. 
Upon  rising  to  his  feet  he  declared  himself  uninjured,  but  soon  after 
complained  of  feeling  faint ;  after  drinking  a  glass  of  brandy  he  felt 
better,  got  into  his  carriage  with  a  friend,  and  drove  home  to  Riving- 
ton  Street  in  this  city,  a  distance  of  more  than  two  miles.  There  was 
so  little  apparent  danger  in  his  case  that  no  physician  was  called  that 
night.  Eai'ly  on  the  morning  of  the  following  day.  Dr.  B.  was  called 
to  visit  him.  He  found  his  patient  reclining  in  his  chair,  in  a  restless 
state,  and  learned  that  he  had  suffered  considerable  pain  in  the  back 
part  of  his  head  and  neck  during  the  night.  He  was  entirely  incapaci- 
tated to  rotate  the  head,  which  led  to  the  suspicion  of  some  injury  to 
the  articulations  of  the  upper  cervical  vertebras ;  but  so  great  a  degree 
of  swelling  existed  about  the  neck  as  to  prevent  efficient  examina- 
tion. There  was  no  paralysis  of  any  portion  of  the  body,  his  pulse 
was  about  90,  and  his  general  system  but  little  disturbed.  Warm 
fomentations  were  applied  to  the  neck,  and  a  mild  cathartic  adminis- 
tered. On  the  following  day  there  was  no  particular  change  in  his 
symptoms,  but  as  there  existed  considerable  nervous  irritability,  tinct. 
hyoscyami  was  prescribed  as  an  anodyne,  and  fomentations  of  hops 
applied  locally.  On  the  third  day,  leeches  were  applied  to  the  neck, 
and  after  this  the  swelling  so  much  subsided,  that  on  the  fifth  day  an 
irregularity  was  discovered  to  exist  in  the  region  of  the  axis  and  atlas, 
which  had  many  of  the  features  of  a  partial  luxation  of  these  vertebrse. 

"  At  this  time  he  began  to  walk  about  the  room,  having  previously 
remained  quiet  on  account  of  the  pain  he  suffered  on  moving.  He 
persisted  in  helping  himself,  and  almost  constantly  supported  his  bead 

'  A.  Cooper  on  Disloc,  etc,  op.  cit.,  p.  476. 


166  FEACTUEES    OF    THE    VEETEBE^. 

with  one  hand  applied  to  the  occiput.  He  often  remarked,  if  he  could 
be  relieved  of  the  pain  in  his  head  and  neck  he  should  feel  well.  He 
began  to  relish  his  food,  and  the  swelling  nearly  disappeared  at  the 
end  of  a  week,  leaving  a  protuberance  just  below  the  base  of  the 
occiput,  to  the  left  of  the  central  line  of  the  spinal  column,  with  a 
corresponding  indentation.  Notwithstanding  strict  orders  to  remain 
quietly  at  home,  on  the  ninth  day  after  the  accident  he  rode  out,  and 
in  a  day  or  two  after  returned  as  actively  as  ever  to  his  former  occu- 
pation of  distributing  milk  throughout  the  city  to  his  old  customers. 
During  the  following  four  months  no  material  change  took  place  in 
his  symptoms,  although  he  constantly  complained  of  pain  in  his  head. 
For  this  period  he  did  not  omit  a  single  day  his  round  of  duties  as  a 
milkman,  which  occupied  him  constantly  and  actively  from  five 
o'clock  in  the  morning  to  nearly  noon.  On  the  first  of  November, 
Prof  Watts  examined  him,  and  inclined  to  the  opinion  that  there  was 
a  luxation  of  the  upper  cervical  vertebree. 

"  About  the  first  of  January,  1853,  the  pains,  from  which  he  had 
been  a  constant  sufferer,  became  more  severe,  and  he  was  heard  to 
complain  that  he  could  not  live  in  his  present  condition  ;  he  remarked, 
also,  that  he  had  heard  a  snapping  in  his  neck.  After  going  his  daily 
round  on  the  eleventh  of  January,  he  complained  of  feeling  cold,  and 
afterwards  of  numbness  in  his  limbs.  In  the  evening  he  had  a  chill 
and  complained  of  a  pain  in  his  bowels.  He  passed  a  restless  night, 
and  arose  on  the  following  morning  about  six  o'clock  ;  he  was  obliged 
to  have  assistance  in  dressing  himself,  and  experienced  a  numbness  of 
his  left,  and  afterwards  of  his  right  side.  He  attempted  to  walk,  but 
could  not  without  help,  and  it  was  observed  that  he  dragged  his  feet. 
He  sat  down  in  a  chair  and  almost  instantly  expired,  at  eight  o'clock 
A.  M.,  on  the  12th  of  January,  precisely  five  months  from  the  receipt 
of  the  injury. 

"  The  autopsy  was  made  thirty  hours  after  death  by  Dr.  C.  E.  Isaacs, 
in  presence  of  several  medical  gentlemen.  Mus- 
Fig.  35.  cular  development  uncommonly  fine.     An  un- 

usual prominence  discovered  in  the  region  of 
the  axis  and  atlas.      On   making  an  incision 
from  the  occiput  along  the  spines  of  the  cervical 
vertebree,  the  parts  were  found  to  be  very  vas- 
cular.    These  vertebrae  were  removed  en  masse, 
and   a   careful    examination    instituted.      The 
transverse,    the    odontoid   (ligamenta   modera- 
toria),  as  also  all  the  ligaments  of  this  region, 
excepting  the  occipito-axoideum,  were  in  a  state 
of  perfect  integrity ;  this   latter  was  partially 
destroyed.      A  considerable  amount  of  coagu- 
lated blood  was  found  effused  between  the  frac- 
Fracture  of  the  odontoid  pro-    turcd  surfaccs,  somc  of  it  apparently  recent,  but 
cess  of  the  axis.  Parker's  case,    much  of  it  was  thought  to  havc  occurrcd  at  the 
A.  Broken  surface.    B.  odon-    ^:^^q  ^f  ^]^q  accidcnt,  and  aftcrwards  to  have 
process.  prevented  the  union  of  the  bones.     The  spinal 

cord  exhibited  no  appearances  of  any  lesion.     The  odontoid  process 


FEACTURES    OF    THE    ATLAS    AND    AXIS.  167 

was  found  in  the  position  well  represented  in  the  accompanying  illus- 
tration, completely  fractured  oft',  and  its  lower  extremity  inclining 
backwards  towards  the  cord.  Death  finally  took  place,  doubtless,  from 
the  displacement  of  the  process  during  some  unfortunate  movement  of 
the  head,  by  which  pressure  was  made  upon  the  cord.  The  destruction 
of  the  occipito-axoid  ligament,  which  would  otherwise  have  protected 
the  contents  of  the  spinal  cavity,  must  have  favored  this  result.'" 


§  6.  Fractures  or  the  Atlas. 

I  have  been  unable  to  find  but  one  example  of  a  fracture  of  the 
atlas  alone,  and  this  is  tbe  case  related  by  Sir  Astley  Cooper  as  having 
come  under  tbe  observation  of  Mr.  Cline. 

A  boy,  about  three  years  old,  injured  his  neck  in  a  severe  fall;  in 
consequence  of  which  he  was  obliged  to  walk  carefully  upright,  as 
persons  do  when  carrying  a  weight  on  the  head ;  and  when  he 
wished  to  examine  any  object  beneath  him,  he  supported  his  chin  upon 
his  hands,  and  gradually  lowered  his  head,  to  enable  him  to  direct  his 
eyes  downwards.  In  the  same  manner,  also,  he  supported  his  head 
from  behind  in  looking  upwards.  Whenever  he  was  suddenly  shaken 
or  jarred,  the  shock  caused  great  pain,  and  he  was  obliged  to  support 
his  chin  with  his  hands,  or  to  rest  his  elbows  upon  a  table,  and  thus 
support  his  head.  The  boy  lived  in  this  condition  about  one  year, 
and  after  death  Mr.  Cline  made  a  dissection  and  ascertained  that  the 
atlas  was  broken  in  such  a  manner  that  the  odontoid  process  of  the 
axis  had  lost  its  support  and  was  constantly  liable  to  fall  back  upon 
the  spinal  marrow.^ 


§  7.  Fractures  of  the  First  two  Cervical  Yertebr^e  (Atlas  and 
Axis)  at  the  same  time. 

A  woman,  set,  68,  fell  down  a  flight  of  steps,  striking  upon  her  fore- 
head, and  died  immediately.  Upon  making  a  dissection,  it  was  found 
that  the  atlas  was  broken  upon  both  sides  near  the  transverse  pro- 
cesses, and  the  odontoid  process  of  the  axis  was  broken  at  its  base. 
These  fractures  were  accompanied  with  a  rupture  of  the  atloido-odon- 
toid  ligaments,  and  a  dislocation  of  the  atlas  backwards.^ 

South  says  there  is  a  specimen  in  the  museum  of  St,  Thomas's  Hos- 
pital, showing  this  double  fracture.  The  man  had  received  his  injury 
only  a  few  hours  before  admission  to  the  hospital,  and  died  on  the 
fifth  day.  On  examination  the  atlas  was  found  to  be  broken  in  two 
places,  and  the  odontoid  process  of  the  axis  at  its  root.  The  fifth  ver- 
tebra was  also  broken  through  its  body.  With  neither  fracture  was 
there  sufficient  displacement  to  produce  pressure,  but  a  small  quantity 

'  Bigelow,  New  York  Journ.  Med.,  March,  1853,  p.  164, 
^  Cline,  Sir  Astley  Cooper,  op.  cit.,  p.  459, 
"  Malgaigne,  op.  cit.,  torn.  ii.  p.  333, 


168  FRACTURES    OF    THE    STERNUM; 

of  extravasated  blood  lay  in  the  substance  of  the  spinal  marrow,  and 
its  tissue  was  at  one  point  broken  down  and  disorganized.^ 

Mr.  Phillips  relates  that  a  man  fell  from  a  haj-rick,  striking  upon 
the  occiput;  after  which,  although  momentarily  stunned,  he  walked 
half  a  mile  to  the  parish  surgeon,  and  in  two  days  more  he  returned 
to  his  occupation.  About  four  weeks  after  the  accident  he  was  seen 
by  Mr.  Phillips,  who  discovered  a  small  tumor  over  the  second  cervi- 
cal vertebra,  pressure  upon  which  caused  a  slight  pain.  He  com- 
plained also  that  his  neck  was  stiff,  and  that  he  was  unable  to  rotate 
it.  No  other  disturbance  of  the  functions  of  the  body  could  be  dis- 
covered. After  a  time  the  tonsils  became  swollen  and  the  patient 
experienced  some  difficulty  in  deglutition,  and  upon  examining  the 
throat,  a  slight  projection  or  fulness  was  discovered  at  the  back  of 
the  larynx,  opposite  the  second  cervical  vertebra.  Subsequently  he 
became  affected  with  general  anasarca  and  pleuritic  effusions,  of  which 
he  finally  died.  Up  to  the  last  week  of  his  life  he  was  able  to  walk 
about  his  bed-room,  and  his  condition  presented  no  other  evidence  than 
has  been  mentioned,  that  he  was  suffering  from  an  injury  of  the  spine. 
He  died  forty-seven  weeks  after  the  receipt  of  the  injury. 

The  autopsy  disclosed  a  fracture  with  displacement  of  the  atlas  and 
a  fracture  of  the  odontoid  process  of  the  axis.  The  two  vertebrae  were 
united  to  each  other  firmly  by  complete  bony  callus.^ 


CHAPTEH    XVI. 

FRACTURES    OF   THE    STERNUM. 

Fractures  of  the  sternum  are  of  rare  occurrence,  owing,  probably, 
to  the  elasticity  of  the  ribs  and  their  cartilages,  upon  which  it  mainly 
rests,  and  also,  in  part,  to  the  softness  of  its  structure.  In  advanced 
life,  the  ossification  and  fusion  of  all  of  its  several  portions  becoming 
more  complete,  and  the  cartilages  of  the  ribs  also  becoming  more  or 
less  ossified,  its  fracture  is  relatively  more  frequent. 

Causes. — They  are  generally  the  result  of  direct  blows  inflicted  upon 
the  part,  such  as  the  passage  of  a  loaded  vehicle  across  the  chest,  the 
fall  of  a  tree  or  of  some  heavy  timber  upon  the  body ;  the  fracture 
implying  always,  that  great  force  has  been  applied. 

Indirect  blows,  and  voluntary  muscular  action  alone  have  been 
known  also  occasionally  to  produce  this  fracture. 

David,  in  his  Memoire  sur  les   Conirecoups,  published  as  a  prize 

'  Chelius's  Surgery,  note  by  South,  vol.  i.  p.  588. 
2  Phillips,  Med.-Chir.  Traus.,  vol.  xx.  1837,  p.  384. 


FEACTUEES    OF    THE    STEEXUM.  169 

essay  by  tlie  Academy  of  Medicine,  mentions  the  case  of  a  mason,  who, 
in  falling  from  a  great  height,  struck  upon  his  back  against  a  cross- 
bar which  intercepted  his  fall,  in  consequence  of  which  the  abdominal 
and  sterno-cleido-mastoidean  muscles  were  so  stretched  that  the  ster- 
num broke  asunder  between  its  upper  and  middle  portions.^  Sabatier 
reports  another  case  of  fracture  at  the  same  point,  produced  in  a  simi- 
lar manner  f  and  Eolland  has  described  a  third  example  in  a  woman 
sixty-three  years  old,  who,  falling  from  a  height  backwards  and  strik- 
ing upon  her  back,  broke  the  sternum  near  its  centre.^ 

Cruveilhier  saw  a  man  who,  having  fallen  from  a  height  of  twenty 
feet  upon  his  nates,  was  found  to  have  a  fracture  of  the  sternum." 
Cussan  saw  the  same  result  in  a  person  who  fell  from  a  third  story, 
striking  first  upon  his  feet  and  then  pitching  over  upon  his  back/ 
Maunoury  and  Thore  have  reported  an  analogous  case,  where  a  man 
fell  from  a  height  of  twelve  or  fifteen  mUres^  first  striking  upon  his 
feet  and  then  falling  over  upon  his  back  and  head."  Mr.  Johnson, 
late  editor  of  the  London  Med.-Chir.  Rev.,  reports  a  case  of  this  kind, 
also,  as  having  been  received  into  St.  George's  Hospital,  in  London ; 
the  man,  a  healthy  laborer,  from  the  country,  had  fallen  from  the  top 
of  a  hay  cart,  striking  only  upon  his  head.  He  walked  with  his  head 
much  bent  forwards,  and  was  incapable  of  either  flexing,  extending, 
or  rotating  it  any  farther.  The  fracture  was  transverse,  and  about 
three  inches  below  the  top  of  the  sternum,  opposite  the  centre  of  the 
third  rib,  the  lower  fragment  projecting  in  front  of  the  upper.  The 
fragments  were  easily  replaced  by  simply  throwing  the  head  back, 
and  they  fell  into  place  with  an  audible  snap,  but  they  immediately 
resumed  their  unnatural  position  when  the  head  was  flexed.  They 
finally  united,  but  with  a  slight  projection  and  overlapping.'' 

Malgaigne  expresses  a  doubt  whether  all  these  can  be  considered 
as  the  results  of  muscular  action,  since  in  a  certain  number  of  the 
examples  cited,  the  head  seems  to  have  been  thrown  forwards  by  the 
concussion,  and  in  others,  also,  there  is  no  evidence  that  the  muscles 
attached  to  the  sternum  were  put  upon  the  stretch.  The  only  re- 
maining explanation  is  that  in  such  cases  the  sternum  has  been 
broken  by  the  violent  shock,  or  contrecoup. 

Seat  and  Direction  of  Fracture. — The  sternum  is  separated  most  fre- 
quently either  in  the  long  central  portion,  or  at  the  junction  of  this 
with  the  upper  portion,  where  the  bone  is  weakest.  In  fact  a  sepa- 
ration at  this  latter  point  may  be  regarded  frequently  as  a  diastasis 
or  dislocation  rather  than  as  a  fracture,  since  the  two  portions  do  not 
become  firmly  united  by  bone  until  late  in  life.  The  very  late  ossifi- 
cation and  fusion  of  the  xiphoid  cartilage  with  the  central  piece,  also, 
will  explain  the  infrequency  of  its  fracture. 

'  Boyer  on  Bones,  p.  57. 

*  Malgaigne,  from  Sabatier,  M6m.  sur  la  Fract.  du  Sternum. 
3  Ibid.,  from  Bull,  de  Th  rap.,  torn.  vi.  p.  288. 

*  Ibid.,  from  Bull,  de  la  Soc.  Anat.,  Juin,  1826. 

5  Ibid.,  from  Archiv.  de  Med.,  Janv.,  1827- 

6  Ibid.,  from  Gaz.  Med.,  1842,  p.  361. 

^  London  Med.-Chir.  Rev.,  vol.  xvii.  new  series,  p.  536,  1832. 


170  FRACTUEES    OF    THE    STERNUM. 

Boyer  believed  that  the  xiphoid  cartilage  was  not  susceptible  of 
being  permanently  displaced  backwards,  except  in  aged  persons  after 
it  had  become  ossified,  "for,"  he  says,  "though  violently  struck  and 
driven  backwards  by  a  blow  on  what  is  vulgarly  termed  the  pit  of  the 
stomach,  yet  it  restores  itself  by  its  own  elasticity.'" 

The  following  case,  however,  which  has  come  under  my  own  ob- 
servation, is  conclusive  as  to  the  possibility  of  this  accident: — 

A  man,  twenty  eight  years  old,  fell  forwards,  striking  the  lower  end 
of  his  sternum  upon  the  top  of  a  candlestick,  breaking  in  the  xiphoid 
cartilage.  During  two  years  following  the  accident  he  had  frequent 
attacks  of  vomiting,  which  were  excessively  violent  and  distressing. 
The  paroxysms  occurring  every  five  or  six  days.  Both  Dr.  Green, 
of  Albany,  and  Dr.  White,  of  Cherry  Valley,  upon  whom  he  called  for 
relief,  recommended  excision  of  the  cartilage,  but  the  patient  would 
not  submit  to  the  operation.  Twelve  years  after  the  accident,  in  the 
year  1848,  while  he  was  an  inmate  of  the  Buffalo  Hospital  of  the 
Sisters  of  Charity,  I  examined  his  chest  and  found  the  xiphoid  car- 
tilage bent  at  right  angles  with  the  sternum,  pointing  directly  towards 
the  spine.  He  now  suffered  no  inconvenience  from  it,  except  that  it 
hurt  him  occasionally  when  he  coughed.^ 

The  upper  portion  of  the  sternum  is  rarely  broken,  unless  at  the 
same  time  the  central  portion  is  broken  also. 

The  direction  of  these  fractures  is  generally  transverse,  or  nearly 
so ;  occasionally  a  slight  obliquity  is  found  in  the  direction  of  the 
thickness  of  the  bone.  In  three  or  four  examples  upon  record  the 
direction  of  the  fracture  was  longitudinal.  It  is  not  so  unfrequent, 
however,  to  find  the  bone  comminuted.  Compound  fractures  are  ex- 
ceedingly rare. 

When  the  fracture  is  transverse,  the  lower  fragment  is  almost  always 
displaced  forwards,  and  sometimes  it  slightly  overlaps  the  upper  frag- 
ment. 

In  one  instance  mentioned  by  Sabatier,  where  the  separation  had 
taken  place  at  the  point  of  junction  between  the  first  and  second 
piece,  the  lower  fragment  was  displaced  backwards,  and  was  also 
carried  upwards  under  the  upper  fragment  to  the  extent  of  twenty- 
eight  milli'metres. 

Diagnosis. — In  a  few  cases  the  patients  have  felt  the  bone  break  at 
the  moment  of  the  accident.  When  displacement  exists  it  may  gene- 
rally be  easily  recognized,  and  the  lower  fragment  will  often  be  seen 
to  move  forwards  and  backwards  at  each  inspiration  and  expiration. 
Crepitus  may  also  be  detected  in  some  of  these  examples,  but  it  is  less 
often  present  where  no  displacement  exists.  To  determine  the  exist- 
ence of  crepitus  the  hand  should  be  placed  over  the  supposed  seat  of 
fracture,  while  the  patient  is  directed  to  make  forced  inspirations  and 
expirations,  or  the  ear  may  be  applied  directly  to  the  chest. 

Emphysema  has,  also,  occasionally  been  noticed,  indicating  usually 
that  the  lungs  have  been  penetrated  by  the  broken  fragments. 

'  Boyer  on  Diseases  of  Bones,  p.  59. 

^  Buffalo  Med.  Journ.,  vol.  xii.  p.  282,  Cases  of  Fractures  of  the  Sternum. 


FEACTUEES    OF    THE    STEENUM.  171 

The  frequent  occurrence  of  congenital  malformations  of  the  sternum 
should  warn  us  to  exercise  great  care  in  our  examinations  lest  we 
mistake  these  natural  irregularities  for  fractures.  Bransby  Cooper 
mentions  a  remarkable  instance  of  malformation  of  the  xiphoid  car- 
tilage which  he  at  first  suspected  to  be  a  fracture.  It  was  so  much 
curved  backwards  that,  as  Mr.  Cooper  thinks,  its  pressure  upon  the 
stomach  produced  a  constant  disposition  to  vomit  whenever  he  had 
taken  a  full  meal,  or  had  taken  a  draught  of  water.' 

Prognosis. — In  simple  fracture  of  this  bone,  uncomplicated  with 
lesions  of  the  subjacent  viscera,  and  especially  where  the  fracture  is 
the  result  of  muscular  action  or  of  a  counter  stroke,  no  serious  con- 
sequences are  to  be  apprehended.  The  bone  unites  promptly  even 
where  it  is  found  impossible  to  bring  its  broken  edges  into  ap- 
position. Indeed,  generally,  where  the  fragments  have  been  once 
completely  displaced,  although  it  is  not  difficult  to  replace  them  mo- 
mentarily, a  re-displacement  soon  occurs,  and  they  are  found  finally  to 
have  united  by  overlapping;  but  no  evil  consequences  usually  result 
from  this  malposition.  In  nearly  all  of  the  cases  reported  in  which 
palpitations,  difficult  breathing,  &;c.,  have  been  charged  to  the  persist- 
ence of  the  displacement,  the  injuries  were  of  such  a  character  as  to 
furnish  for  these  unfortunate  results  other  and  much  more  adequate 
explanations.  In  one  instance  only,  already  mentioned,  serious  incon- 
veniences followed  from  a  displacement  of  the  cartilage  backwards. 

In  other  cases,  however,  where  the  fracture  is  the  result  of  a  direct 
blow,  constituting  a  large  majority  of  the  whole  number,  the  prognosis 
is  often  very  grave:  a  conclusion  to  which  one  would  naturally  arrive 
from  the  fact  already  stated,  that  the  fracture  of  the  sternum  thus 
produced,  in  itself  implies  the  application  of  great  force. 

An  abscess  occurring  in  the  anterior  mediastinum,  and  caries  or 
necrosis  of  the  bone,  are  among  the  most  common  results  of  a  blow 
delivered  directly  upon  the  sternum;  complications  which  generally 
end  sooner  or  later  in  death.  Blood  may  be  also  extensively  effused 
into  the  anterior  mediastinum. 

Where  emphysema  is  present  we  may  anticipate  inflammation  of 
the  pleura  and  of  the  lungs. 

In  several  instances,  where  death  has  occurred  speedily  after  the 
injury,  the  heart  has  been  found  penetrated  and  torn  by  the  fragments. 
Sanson  and  Dupuytren  have  each  reported  one  example  of  this  kind. 
Duverney  has  mentioned  two,  and  Samuel  Cooper  says  there  is  a 
specimen  in  the  museum  of  the  University  College,  exhibiting  a  lace- 
ration of  the  right  ventricle  of  the  heart  by  a  portion  of  fractured 
sternum.  Watson  mentions  a  case  in  which  the  pericardium  was  torn, 
but  the  heart  was  only  contused.^ 

Treatment. — When  the  fragments  are  not  displaced,  the  only  indi- 
cations of  treatment  are  to  immobilize  the  chest,  and  to  allay  the  in- 
flammation, pain,  &c.,  consequent  upon  the  injury  to  the  viscera  of  the 
chest.     The  first  of  these  indications  is  accomplished,  at  least  in  some 

'  B.  Cooper,  Princ.  and  Prac.  of  Surg.,  p.  359. 
2  New  York  Journal  Med.,  vol.  iii.  p.  351. 


172  FEACTUEES    OF   THE    STEENUM. 

degree,  by  inclosing  the  body,  from  the  armpits  down  to  the  margin 
of  the  floating  ribs,  with  a  broad  cotton  or  flannel  band.  A  single 
band,  neatly  and  snugly  secured,  and  made  fast  with  pins,  is  preferable 
to,  because  it  is  more  easily  applied  than  the  roller  which  surgeons 
have  generally  employed ;  it  is  also  much  less  liable  to  become  dis- 
arranged. It  should  be  pinned  while  the  patient  is  making  a  full 
expiration.  To  prevent  its  sliding  down,  two  strips  of  bandage  should 
be  attached  to  its  upper  margin  and  crossed  over  the  shoulders  in  the 
form  of  suspenders. 

Generally  the  patients  prefer  the  half  sitting  posture,  with  the  head 
and  shoulders  thrown  a  little  backwards ;  and  this  is  the  position 
which  will  be  most  likely  to  maintain  the  fragments  in  place,  and  also 
to  secure  immobility  to  the  external  thoracic  muscles,  while  it  leaves 
the  diaphragm  and  the  abdominal  muscles  free  to  act. 

The  second  indication  may  demand  the  use  of  the  lancet ;  but  more 
often  it  will  be  found  necessary  to  allay  the  pain  and  disposition  to 
cough  by  the  use  of  opium. 

If,  however,  the  fragments  are  displaced,  it  is  proper  first  to  attempt 
their  reduction;  which,  as  we  have  already  intimated,  is  generally 
more  easy  of  accomplishment  than  is  the  maintenance  of  them  in  place 
until  a  cure  is  effected. 

The  upper  fragment  may  be  thrown  forwards,  and  made  to  resume 
its  position  sometimes  by  a  single  full  inspiration  ;  but  then  it  usually 
falls  back  during  expiration ;  or  it  may  be  reduced  by  straightening 
the  spine  forcibly  and  at  the  same  time  drawing  the  shoulders  back. 

Verduc  and  Petit  proposed,  in  those  cases  in  which  it  was  found 
impossible  to  reduce  the  fragments  by  these  simple  means,  to  cut 
down  and  lift  the  depressed  bone.  Nelaton  suggests  the  use  of  a  blunt 
crotchet  introduced  through  a  narrow  incision ;  and  Malgaigne  has 
thought  of  another  plan,  which  is,  to  penetrate  the  skin  with  a  punch, 
and  directing  it  to  the  broken  margin,  to  push  the  fragment  into  its 
place,  but  which  he  does  not  himself  regard  as  a  suggestion  of  much 
value,  since  the  bone  is  too  soft  to  afford  the  necessary  resistance ;  and, 
moreover,  this,  in  common  with  all  of  the  other  similar  methods,  is 
liable,  in  some  degree,  to  the  objection  that  it  may  increase  the  tend- 
ency to  caries  and  suppuration,  already  imminent.  If  reduced,  the 
fragments  will  probably  immediately  again  become  displaced ;  and 
more  than  all,  it  still  remains  to  be  proven  conclusively,  that  the  mere 
riding  of  the  fragments  is  in  itself  ever  a  cause  of  subsequent  suffering 
or  even  of  inconvenience. 

When  an  abscess  has  formed  in  the  anterior  mediastinum,  surgeons 
have  occasionally  recommended  the  use  of  the  trephine.  Gibson  has 
twice  operated  in  this  manner  at  the  Philadelphia  Hospital,  but  in 
each  case  the  caries  continued  to  extend  and  the  patient  died ;  an 
experience  which  has  inclined  him  latterly  to  discountenance  the 
operation.^ 

There  are  other  considerations  mentioned  by  Lonsdale,  which  ought 
to  decide  us  never  to  use  the  trephine  in  these  cases.    "  For  the  symp- 

'  Gibson,  Institutes  and  Practice  of  Surgery,  vol.  i.  p.  269. 


FEACTUEES    OF    THE    EIBS.  173 

toms  denoting  the  presence  of  the  abscess,  when  completely  confined 
to  the  under  surface  of  the  bone,  will  be  very  uncertain ;  and  when 
the  matter  collects  in  larger  quantities,  it  will  show  itself  at  the  margin 
of  the  sternum,  between  the  ribs;  when  it  can  be  let  out  by  making 
a  puncture  with  the  point  of  a  lancet,  without  the  necessity  of  remov- 
ing a  portion  of  the  bone.'" 

We  have  already  said  that  a  separation  of  the  first  from  the  second 
piece  of  the  sternum,  occurring  before  ossific  union  had  taken  place, 
might  with  some  propriety  be  regarded  as  a  diastasis,  or  as  a  dis- 
location even.  Maisonneuve,  Vidal  (de  Casis),  Malgaigne,  and  other 
French  surgeons  speak  of  it  as  a  dislocation,  and  Vidal  has  collected 
five  examples,  in  all  of  which  the  lower  bone  occupied  a  position  in 
front  of  the  upper.  Malgaigne  enumerates  ten  examples.  The  points 
of  difference  between  the  dislocation  and  the  true  fracture  are  too 
small,  however,  to  demand  of  us  especial  attention. 


CHAPTEE    XVII. 

FEACTUEES    OF   THE   EIBS  AND   THEIE   CAETILAGES. 
§  1.  Fractures  of  the  Ribs. 

Feactuees  of  the  ribs,  observed  more  often  than  fractures  of  the 
sternum,  are  rare  as  compared  with  fractures  of  other  long  bones. 

In  my  records  only  eighteen  patients  are  reported  as  having  had 
broken  ribs ;  but  as  in  several  of  the  cases  two  or  more  ribs  were 
broken  at  the  same  time,  the  total  number  of  fractures  is  about 
thirty-six.  If,  however,  I  had  always  accepted  the  diagnosis  made  by 
other  surgeons,  the  number  would  have  been  much  greater,  since  I 
have  been  repeatedly  assured  that  the  ribs  were  broken  where,  upon 
the  most  rigid  examination,  no  evidence,  beyond  the  existence  of  a 
severe  pain  and  of  difficult  respiration,  has  been  presented  to  me. 

Etiology. — The  force  requisite  to  break  the  ribs  is  scarcely  less  than 
what  is  requisite  to  break  the  sternum ;  and  in  childhood  and  infancy 
it  is  sometimes  almost  impossible  to  break  them,  so  that  children  and 
even  adults  are  often  crushed  and  killed  outright,  where,  although  the 
pressure  has  been  directly  upon  the  thorax,  the  ribs  have  resumed  their 
positions,  and  have  been  found  not  to  be  broken.  I  have  met  with 
several  examples  of  this  kind. 

In  old  age,  the  cartilages  ossify  and  the  ribs  themselves  suffer  a 
gradual  atrophy,  which  renders  them  much  more  liable  to  break. 

"  Lousdale,  Practical  Treatise  on  Fractures,  London,  1838,  p.  242. 


174:      FEACTURES    OF   THE    RIBS    AND    THEIR    CARTILAGES. 

The  most  common  causes  are  direct  blows,  of  very  great  force,  in 
consequence  of  which  sometimes  the  fragments  are  not  only  broken, 
but  more  or  less  forced  inwards;  occasionally  they  are  the  result  of 
counter-strokes,  and  then  the  fragments,  if  they  deviate  at  all  from  their 
natural  position,  are  salient  outwards ;  a  species  of  fracture  which  I 
have  not  met  with  so  often. 

Malgaigne  has  collected  eight  examples  of  fractures  of  the  ribs  pro- 
duced by  muscular  action,  by  the  beating  of  the  heart,  &c.,  all  of  which 
occurred  upon  the  left  side.  It  is  believed,  however,  that  in  all  of  these 
cases  the  ribs  had  previously  become  atrophied,  and  perhaps  under- 
gone other  changes  in  their  structure,  rendering  them  liable  to  fracture 
from  the  action  of  trivial  causes. 

Pathology,  Seat,  &c. — The  fourth,  fifth,  sixth,  and  seventh  ribs  are 
most  liable  to  be  broken ;  the  upper  ribs,  and  especially  the  first  rib, 
being  so  well  protected  in  various  ways  as  to  greatly  diminish  their 
liability,  while  the  loose  and  floating  condition  of  the  last  two  ribs 
gives  them  an  almost  complete  exemption. 

In  my  own  cases  I  have  found  the  first,  second,  and  third  ribs  each 
broken  once,  the  fourth  three  times ;  the  fifth  and  sixth,  nine  times ; 
the  seventh,  six  times ;  the  eighth,  ninth,  and  tenth,  twice  each. 

Twenty-one  were  broken  through  their  anterior  thirds,  generally  at 
or  near  the  junction  of  the  cartilages  with  the  ribs;  five  through  their 
middle  thirds  ;  and  ten  through  their  posterior  thirds.  Malgaigne 
has  noticed,  also,  contrary  to  the  general  opinion  of  surgeons,  that  the 
ribs  are  most  often  broken  in  their  anterior  thirds,  whether  the  cause 
has  been  a  direct  or  a  counter  blow. 

The  direction  of  the  fracture  is  generally  transverse  or  slightly  ob- 
lique ;  sometimes  it  is  quite  oblique.  It  is  often  compound  ;  and  in  a 
few  instances  1  have  found  it  comminuted  or  multiple.  Where  the  frac- 
ture is  compound,  it  is  rendered  so  generally  by  the  fragments  having 
penetrated  the  lungs,  and  not  by  a  tegumentary  wound.  In  only  nine 
of  the  eighteen  cases  seen  by  me,  has  the  fracture  been  uncomplicated 
with  fractures  or  dislocations  of  other  bones. 

Displacement  cannot  occur  in  the  direction  of  the  axis  of  the  bone 
unless  several  ribs  be  broken  at  the  same  time.  The  fragments  are 
therefore  either  not  at  all  displaced,  or  they  fall  inwards  toward  the 
cavity  of  the  chest,  or  outwards,  or  very  slightly  downwards,  in  the 
direction  of  the  intercostal  spaces.  Sometimes  the  rib  moves  a  little 
upon  its  own  axis. 

Prognosis. — Death  occurs  sooner  or  later  in  a  pretty  large  propor- 
tion of  the  cases  in  which  the  ribs  have  been  broken ;  yet  not  often 
as  a  direct  consequence  of  the  fracture,  but  only  as  a  result  of  the 
injury  inflicted  upon  the  viscera  of  the  chest,  or  of  other  injuries  re- 
ceived at  the  same  moment.  The  violent  compression  of  the  heart 
and  lungs  has  frequently  produced  death,  and  sometimes,  as  I  have 
more  than  once  seen,  almost  immediately ;  or  the  patients  have  suc- 
cumbed at  a  later  period  to  acute  pneumonitis. 

Lonsdale  saw  a  case  in  which  the  body  of  a  man  having  been  tra- 
versed by  the  wheel  of  a  wagon,  eight  ribs  were  broken,  and  death 
having  followed  almost  immediately,  the  autopsy  disclosed  a  rent  in 


FEACTUEES    OF    THE    EIBS.  175 

the  left  auricle  of  tlie  heart,  produced  by  one  of  the  broken  ribs.' — 
South  says  there  is  such  a  specimen  in  St.  Thomas's  Hospital.'^ 

Dupuytren  reports  a  similar  case.  The  same  surgeon  has  also  seen 
several  deaths  produced  by  the  emphysema,  independent  of  the  frac- 
ture, two  of  which  are  particularly  described  in  his  Clinical  Lectures.^ 
Amesbury  has  seen  a  case  of  death  from  rupture  of  the  intercostal 
artery,  where  there  was  no  injury  of  the  lungs.'* 

In  several  instances  observed  by  me,  patients  have  suffered  from 
pains  in  the  side,  occasionally  from  cough,  &c.,  after  the  lapse  of  two 
or  more  years,  and  I  suspect  it  is  no  uncommon  thing  for  ttiese  injuries 
to  entail  some  such  permanent  disability,  but  which  is  a  consequence 
rather  of  the  injury  to  the  viscera  of  the  chest  than  of  any  condition 
of  the  broken  ribs  themselves. 

In  general,  simple  fractures  of  the  ribs  unite  in  from  twenty-five  to 
thirty  days.  Malgaigne  has  seen  one  case  of  non-union ;  Haguier  met 
with  another  upon  the  cadaver,  in  which  a  complete  false  joint  existed, 
furnished  with  a  capsule  and  lined  with  synovial  membrane;^  Eve,  of 
Nashville,  Tenu.,  saw  a  case  of  non-union  occasioned,  probably,  by  a 
caries  or  necrosis  of  the  bone,  since  it  was  accompanied  with  a  dis- 
charge of  matter,  and  in  which  a  removal  of  the  ends  of  the  fragments 
resulted  promptly  in  a  cure  of  the  sinus;^  and  Samuel  Cooper  says 
there  is  a  specimen  in  the  museum  of  the  University  College,  of  a 
fracture  of  six  ribs,  where  the  fragments  are  only  connected  by  a 
fibrous  or  ligamentoas  tissue.^ 

The  union  generally  occurs  with  only  a  slight  degree  of  displace- 
ment. 

After  the  union  is  completed,  even  where  there  is  no  displacement, 
a  certain  amount  of  ensheathing  callus  may  generally  be  felt  at  the 
point  of  fracture.  Of  five  cases  which  I  have  carefully  examined  after 
recovery,  in  only  one  instance  was  I  unable  to  detect  any  irregularity 
at  this  point.  I  have  in  my  cabinet  nine  specimens  of  fractured  ribs, 
in  four  of  which  the  ensheathing  callus  is  completely  formed,  but  the 
fragments  are  in  perfect  apposition:  in  one,  apposition  is  preserved, 
but  there  is  no  ensheathing  callus ;  and  the  remaining  four,  all  occur- 
ring in  the  same  person,  are  united  with  displacement,  but  without  a 
proper  ensheathing  callus. 

In  some  specimens  I  have  observed  sharp  spiculee  of  bone  or  osteo- 
phytes extending  along  the  course  of  the  intercostal  muscles  from  one 
rib  to  the  other,  forming  a  species  of  anchylosis  between  their  adjacent 
margins. 

SymiAomatohgy. — Acute  pain,  referred  especially  to  the  point  of 
fracture,  sometimes  producing  great  embarrassment  in  the  respiration, 
and  crepitus,  are  the  most  common  indications  of  a  fracture.  The  pain 
and  embarrassed  respiration  are,  however,  far  from  being  diagnostic, 
since  they  are  often  present  in  an  equal  degree  when  the  walls  of  the 
chest  have  only  been  severely  contused. 

'  Lonsdale  on  Fractures,  p.  258.  ^  Chelius's  Surgery,  by  South,  vol.  i.  p.  599. 

3  Dupuytren,  op.  cit.,  p.  79.  *  Amesbury  on  Fractures,  vol.  ii.  612. 

=  Malgaigne,  op.  cit.,  p.  435.  ®  Eve,  N.  Y.  Journ.  Med.,  vol.  xv.  p.  136. 

'  S.  Cooper's  Surg.,  vol.  ii.  p.  321. 


176      FEACTURES    OP    THE    RIBS    AND    THEIR    CARTILAGES. 

The  crepitus,  also,  is  often  difficult  to  detect,  owing  to  the  thickness 
of  the  muscular  coverings,  or  to  the  amount  of  fat  upon  the  body,  or 
to  the  fracture  having  occurred  perhaps  directly  underneath  the  mam- 
mae in  the  female.  In  three  instances,  where  the  presence  of  emphy- 
sema rendered  the  existence  of  a  fracture  quite  certain,  I  have  been 
unable  immediately  after  the  accident  to  discover  crepitus. 

The  crepitus  may  be  discovered  sometimes  by  pressing  gently  upon 
the  seat  of  fracture,  or  by  applying  the  ear  or  the  stethoscope  over 
this  point  while  the  patient  attempts  a  full  inspiration,  or  coughs;  or 
we  may  press  upon  the  front  of  the  chest  with  one  hand,  while  the 
fingers  of  the  other  hand  rest  upon  the  fracture. 

Occasionally  the  patient  has  felt  the  bone  break,  and  very  often  he 
feels  or  hears  the  crepitus  after  it  is  broken  and  will  himself  indicate 
very  clearly  the  point  of  fracture. 

At  the  same  time  that  we  detect  crepitus  we  are  able  also  to  discover 
motion  in  the  fragments,  but  I  have  once  or  twice  discovered  preter- 
natural mobility  without  crepitus. 

Emphysema,  which  is  almost  certainly  indicative  of  a  fracture,  is 
present  in  a  pretty  large  proportion  of  cases.  It  has  been  observed  by 
me  in  ten  out  of  eighteen  cases ;  generally  it  did  not  extend  over  more 
than  two  or  three  square  feet  of  surface  ;  but  in  one  instance  it  finally 
extended  over  nearly  the  whole  body.  It  is  remarkable,  however,  that 
in  only  three  of  these  ten  cases  did  the  patients  expectorate  blood, 
and  then  in  a  very  small  quantity,  and  not  until  the  second  or  third 
day.  - 

Desault  observes  that  emphysema  rarely  succeeds  to  fractures  of  the 
ribs ;  an  observation  which,  as  will  be  seen,  my  experience  does  not 
at  all  confirm. 

Treatment. — In  simple  fractures,  where  there  is  no  displacement,  or 
where  the  displacement  is  only  moderate,  the  chest  may  be  inclosed 
with  a  broad  belt  or  band,  as  we  have  already  directed  in  case  of  frac- 
ture of  the  sternum  :  provided  always  that  it  is  not  found  to  increase 
instead  of  diminishing  the  patient's  sufferings.  Some  patients  cannot 
tolerate  this  confinement  at  all,  while  with  a  majority,  although  it  is 
at  first  uncomfortable  and  oppressive,  after  an  hour  or  two  it  affords 
them  great  relief  from  the  distressing  pain,  and  they  will  not  consent 
to  have  it  removed  even  for  a  moment.  In  nearly  all  cases  of  com- 
minuted, or  multiple  fracture,  it  is  inadmissible,  on  account  of  its 
tendency  to  force  the  pieces  inwards. 

Hannay,  of  England,' has  suggested  the  use  of  adhesive  straps  as  a 
substitute  for  the  cotton  or  flannel  band ;  the  several  successive  pieces 
being  imbricated  upon  each  other  until  the  whole  chest  is  covered.* 
The  same  objection  holds  to  this  mode  of  dressing  as  to  a  similar  mode 
of  dressing  a  broken  clavicle,  which  has  been  recently  recommended. 
It  will  certainly  become  loosened  after  a  few  hours,  by  the  slight  but 
uninterrupted  play  of  the  ribs. 

The  forearm  ought  also  to  be  brought  across  the  chest  at  a  right 
angle  with  the  arm,  and  secured  in  this  position  with  a  moderately 

'  American  Journ.  Med.  Sci.,  vol.  xxxix.  p.  198.     From  Lond.  Med.  Gaz.,  Nov.  1845. 


FRACTURES    OF    THE    RIBS,  177 

tight  bandage  or  sling,  so  as  to  prevent  any  motion  in  the  pectoral 
muscles. 

As  to  position,  the  patient  generally  prefers  to  sit  up,  or  he  chooses 
a  position  only  partly  reclining  upon  his  back;  but  there  is  no  positive 
rule  to  be  observed  in  this  matter,  except  that  such  a  position  shall  be 
chosen  as  shall  prove  most  comfortable  to  the  patient. 

If  the  fragments  are  salient  outwards,  the  fracture  having  been  pro- 
duced by  a  counter-stroke,  they  may  be  reduced  by  pressing  gently 
upon  them  from  without.  If,  on  the  contrary,  the  fragments  are  salient 
inwards,  they  will  be  found,  in  a  great  majority  of  cases,  to  have  re- 
sumed their  positions  spontaneously  or  through  the  natural  actions  of 
respiration ;  but  if  they  have  not,  it  will  be  exceedingly  difficult  to 
restore  them.  Possibly  it  may  be  accomplished  by  pressing  forcibly 
npon  the  front  of  the  chest,  or  upon  the  anterior  extremity  of  the 
broken  rib;  yet  if  the  fragments  are  comminuted,  and  the  ends  are 
much  driven  in,  this  method  will  avail  little  or  nothing.  In  such  cases 
several  surgeons  have  recommended  that  we  should  cut  down  to  the 
bone  and  elevate  the  fragments,  but  Rossi  alone  claims  to  have  actu- 
ally put  the  suggestion  into  practice. 

No  doubt,  if  the  necessity  was  urgent,  this  method  might  be  suc- 
cessfully adopted;  or,  instead  of  cutting  down  to  the  broken  rib,  we 
might  even  seize  the  fragment  with  a  hook,  as  suggested  by  Malgaigne, 
or,  what  in  some  cases  might  be  even  more  convenient,  with  a  pair  of 
forceps  constructed  with  long  teeth,  obliquely  set  upon  a  firm  shaft. 
Yet  the  exigency  which  will  demand  a  resort  to  any  of  these  measures 
wjll  be  exceedingly  rare. 

In  no  case  do  I  attach  any  value  or  importance  to  the  advice  given 
by  Petit,  that  we  shall  place  a  compress  upon  the  front  of  the  chest, 
underneath  the  bandage,  in  order  to  reduce  the  fragments,  or  to  retain 
them  in  place  after  reduction.  Lisfranc,  who  advocated  this  method, 
claimed  that  its  advantage  consisted  in  the  increased  length  which 
was  thus  given  to  the  antero-posterior  diameter  of  the  chest,  and  the 
consequent  accumulation  of  pressure  from  the  encircling  band,  in  this 
direction.'  The  mechanical  law  is  no  doubt  correctly  stated,  but  its 
value  in  practice  is  too  inconsiderable  to  deserve  consideration. 

The  emphysema  generally  demands  no  especial  attention,  since  it  is 
usually  too  limited  to  occasion  inconvenience,  and  when  more  exten- 
sive it  generally  disappears  spontaneously  after  a  few  days,  or  a  few 
weeks  at  most.  The  advice  given  by  some  surgeons,  that  we  ought 
in  these  cases  to  cut  down  to  the  pleural  cavity  so  as  to  allow  the  air 
to  escape  freely  through  the  incision,  seems  thus  far  to  have  rested  its 
reputation  upon  a  more  than  doubtful  theory  rather  than  upon  any 
testimony  of  experience.  Abernethy  alone,  so  far  as  I  know,  has 
actually  made  the  experiment,  and  his  patient  died. 

Dupuytren,  in  the  two  cases  already  alluded  to,  bled  the  patients 
and  applied  resolvent  liquids,  with  rollers;  he  also  made  incisions 
with  the  lancet  at  various  points  of  the  body,  more  or  less  remote  from 

'  Ranking's  Abstract,  vol.  ii.  p.  204,  from  Gaz.  des  Hopitaux,  July  8,  1845. 

12 


178      FEACTUEES    OF    THE    EIBS   AND    THEIE   CAETILAGES. 

the  seat  of  fracture,  a  practice,  however,  in  which  he  confesses  he  has 
no  contidence  whatever.     These  patients  both  died. 

Dr.  Stedman,  of  the  Massachusetts  Greneral  Hospital,  has  reported  the 
case  of  a  man  aged  sixty-nine,  of  intemperate  habits,  who,  in 'addition  to 
a  fracture  of  one  of  his  ribs,  had  also  a  dislocation  of  the  outer  end  of 
the  clavicle.  The  emphysema  commenced  immediately  and  reached 
its  acme  on  the  twenty-second  day.  At  this  time  it  had  extended  over 
his  whole  bod}' ;  his  eyes  were  closed  and  he  breathed  with  great 
difficulty ;  but  on  the  forty-fifth  da}'-,  the  emphysema  had  entirely 
disappeared,  and  he  was  dismissed  cured.  The  treatment  consisted 
chiefly  in  the  free  internal  use  of  stimulants,  and  in  the  application  of 
bandages ;  but  the  bandages  soon  became  disarranged,  and  after  a  few 
days  they  were  entirely  laid  aside.^ 

In  the  case  of  my  own  patient,  where  the  emphysema  was  almost 
equally  extensive,  the  patient  recovered  after  a  few  weeks,  under  the 
use  of  a  simple  diet,  and  without  any  special  medication  whatever. 


§  2.  Fractures  of  the  Cartilages  of  the  Ribs. 

Boyer  was  incorrect  when  he  said  that  the  cartilages  of  the  ribs 
could  not  be  broken  until  they  were  ossified.  They  are  often  broken 
when  there  is  no  ossification,  at  the  same  time  that  the  ribs  themselves 
are  broken.  Sometimes  they  are  broken  alone.  Not  unfrequently, 
also,  the  separation  takes  place  at  the  precise  point  of  junction  between 
the  two. 

Pyper  relates  a  case  in  which  the  sternum  was  broken  in  a  man 
aged  twenty-five  years,  and  also  the  cartilages  of  the  sixth,  seventh,  and 
eighth  ribs  of  the  right  side,  as  was  proven  by  the  autopsy,  yet  the 
cartilages  were  not  ossified.  The  vena  cava  ascendens  was  also  rup- 
tured by  the  force  of  the  compression.^ 

Etiology. — The  causes  are  the  same  as  those  which  produce  fractures 
of  the  ribs,  yet  it  is  generally  understood  that  it  will  require  greater 
force,  and  that  consequently  the  injury  done  to  the  viscera  of  the 
thorax  will  be  more  complicated  and  intense. 

In  the  reports  of  the  Massachusetts  General  Hospital,  an  account  is 
given  of  the  case  of  a  man  aged  thirty,  who  was  crushed  by  the  fall 
of  a  heavy  weight  upon  his  body,  and  who  died  after  about  sixty 
hours.  An  examination  after  death  revealed  a  fracture  of  the  car- 
tilages of  the  third  and  fourth  ribs,  with  a  laceration  of  the  intercostal 
muscles  to  such  an  extent  that  a  hernia  of  the  lungs  had  occurred  at 
this  point.  This  hernia  had  been  discovered  and  recognized  by  Dr. 
Warren,  soon  after  the  accident  occurred  ;  the  protrusion  being  at 
that  time  as  large  as  the  clenched  fist  and  regularly  rising  and  falling 
with  each  movement  of  respiration.  It  was  accompanied,  also,  with  a 
moderate  emphysema. 

Pathology. — The  fracture  is  clean  and  vertical,  or  transverse ;  never 
irregular  or  oblique.     The  direction  of  the  displacement  varies  as  in 

'  Boston  Med.  and  Surg.  Journ.,  vol.  lii.  p.  316. 

*  Ranking's  Abstract,  vol.  i.  p.  147,  from  the  Lancet,  Oct.  1844. 


FEACTURES  OF  THE  CLAVICLE.  179 

fractures  of  the  ribs,  but  the  anterior  or  sternal  fragment  is  generally 
found  in  front  of  the  posterior  or  spinal. 

Union  takes  place  in  these  fractures,  not  through  the  medium  of 
cartilage,  but  of  bone.  Sometimes  the  new  bone  being  deposited  only 
between  the  ends  of  the  fragments,  in  the  form  of  a  thin  plate,  and  at 
other  times  it  is  formed  around  the  fragments  as  well  as  between 
them.  The  latter  of  these  two  processes  has  been  most  frequently 
observed.  The  ensheathing  callus  appears  to  be  supplied  by  the 
perichondrium,  while  the  experiments  of  Dr.  Redfern  render  it  prob- 
able that  the  intermediate  callus  may  result  from  a  conversion  or 
transformation  of  the  adjacent  cartilaginous  surfaces.  Paget  remarks, 
also,  that  the  ossification  extends  to  the  parts  of  the  cartilage  imme- 
diately adjacent  to  the  fracture. 

I  do  not  know  that  any  observations  have  been  made  upon  the 
repair  of  these  cartilages  in  very  early  life,  and  it  is  possible  that  the 
process  may  differ  from  this  which  has  been  described  as  it  has  been 
observed  in  the  adult. 

Treatment. — The  treatment  need  not  differ  from  that  already  recom- 
mended for  fractured  ribs. 


CHAPTER    XVIII. 

FRACTUEES   OF   THE   CLAVICLE. 

For  the  sake  of  convenience,  I  shall  divide  fractures  of  the  clavicle 
into  those  occurring  through  the  inner,  middle,  and  outer  thirds.  By 
the  "  outer  third"  is  meant  all  that  portion  of  the  clavicle  included 
between  its  scapular  extremity  and  the  internal  margin  of  the  conoid 
ligament.  The  remaining  portion  is  intended  to  be  divided  equally 
into  two  separate  thirds.  The  peculiarities  of  these  several  portions, 
in  respect  to  anatomical  relations,  liability  to  fracture,  results,  etc., 
will  explain  the  propriety  of  the  divisions. 

Gcmses. — The  clavicle  is  broken,  in  a  large  majority  of  cases,  by  a 
counter  stroke,  such  as  a  fall,  or  a  blow  upon  the  extremity  of  the 
shoulder. 

Occasionally  it  is  broken  by  a  direct  stroke,  as  when  a  blow  aimed 
at  the  head  is  received  upon  the  shoulder;  it  is  broken  sometimes  by 
the  recoil  of  an  overloaded  gun,  especially  when  the  person  lies  upon 
the  ground  with  the  but  of  the  gun  resting  against  the  clavicle. 

Gibson  has  seen  a  case  in  which  it  was  broken  in  a  child  at  birth, 
by  an  ignorant  midwife  pulling  at  the  arm.^ 

I  have  once  seen  the  clavicle  broken  by  muscular  action  alone.  A 
large,  well-built  and  healthy  man,  aged  thirty-seven,  standing  upon 

'  Gibson,  Principles  of  Surg.,  sixth  ed.,  vol.  i.  p.  272. 


180  FRACTUEES    OF   THE    CLAVICLE. 

the  ground,  attempted  to  secure  the  braces  of  his  carriage  top  with  his 
right  arm,  when  he  felt  a  sudden  snap,  as  if  something  about  his 
shoulder  had  given  way.  He  did  not,  however,  suspect  the  nature  of 
the  injury,  and  did  not  consult  any  surgeon  until  eight  days  after,  at 
which  time  I  found  the  right  clavicle  broken  near  its  centre,  but 
rather  nearer  the  sternal  than  scapular  extremity.  The  fragments 
were  but  slightly,  if  at  all  displaced,  but  motion  and  crepitus  at  the 
point  of  fracture  were  distinct.  The  usual  node-like  swelling  was 
also  present,  indicating  the  existence  of  a  considerable  amount  of  en- 
sheathing  callus.  He  had  been  unable  to  raise  the  arm  to  a  right 
angle  with  the  body  since  it  was  broken,  but  he  had  suffered  no  other 
inconvenience  from  it. 

A  similar  case  is  reported  in  the  number  for  January,  1843,  of  the 
American  Journal  of  Medical  Sciences^  copied  from  the  Revista  Medica. 
The  subject  of  this  case  was  a  colonel  of  cavalry,  about  sixty  years  of 
age.  In  mounting  his  horse,  he  experienced  a  sensation  as  if  some- 
thing had  broken,  followed  by  acute  pain  in  his  left  shoulder,  and,  on 
examination,  it  was  found  that  the  clavicle  was  fractured  in  the  mid- 
dle. The  health  of  this  gentleman  had  been  impaired,  it  is  further 
stated,  by  repeated  attacks  of  syphilis. 

Malgaigne  has  recorded  three  other  examples  of  fracture  of  this 
bone  from  muscular  action ;  and  Parker  saw  a  case  which  was  pro- 
duced by  striking  at  a  dog  with  a  whip ;  the  bone  had  been  previously 
somewhat  diseased,  yet  it  united  favorably,^ 

Of  'these  six  cases,  five  occurred  on  the  right  side,  and  always  near 
the  middle  of  the  bone,  if  we  except  one  case  reported  by  Malgaigne, 
in  which  the  point  of  fracture  is  not  mentioned.  In  neither  case  did 
the  fragments  become  displaced,  only  as  they  were  found,  in  some  of 
the  examples,  inclined  slightly  forwards. 

Pathology. — It  has  already  been  observed,  in  speaking  of  partial 
fractures,  that  this  bone  suffers  an  incomplete  fracture  more  often 
than  any  other,  and  that  in  such  cases,  the  lesion  occurs  generally  in 
the  middle  third,  or  rather  to  the  sternal  side  of  the  centre,  and  in  a 
direction  nearly  or  quite  transverse.  They  are  not  usually  accom- 
panied with  much  displacement,  but  if  a  displacement  exists,  it  is  a 
slight  forward  inclination  of  the  fragments. 

Fractures  which  are  complete  occur  mostly  after  the  bones  have 
become  firm  and  unyielding.  They  are  also  generally  oblique,  seldom 
comminuted,  still  more  rarely  compound.  The  point  of  the  clavicle 
at  which  a  complete  fracture  usually  occurs,  is  at  or  near  the  outer  end 
of  the  middle  third,  and  a  little  to  the  sternal  side  of  the  coraco-clavi- 
eular  ligaments,  near  where  the  trapezius  and  deltoid  cease  their 
attachments.  It  might  be  more  exact  to  say,  that  the  fracture  extends 
i'rom  this  point  downwards  and  inwards,  toward  the  sternum,  em- 
bracing one  inch  or  less  of  its  entire  length.  In  some  cases  the  obli- 
(juity  is  greater,  and  the  amount  of  bone  involved  is  much  more 
considerable. 

Why  the  bone  should  break  more  frequently  at  this  point,  espe- 
cially in  the  adult  and  in  the  male,  it  is  not  difficult  to  understand.     It 

'  Parker,  N.  Y.  Journ.  Med.,  July,  1852. 


FEACTURES    OF    THE    CLAVICLE. 


181 


Fig.  36. 


is  smaller  here  than  elsewhere,  and  less  supported  by  muscular  and 
ligamentous  attachments.  At  this  point,  also,  the  axis  of  the  bone 
begins  pretty  abruptly  to  curve  forwards,  and  more  abruptly  in  the 
adult  and  male,  than  in  the  child  and  female.  When,  therefore,  the 
clavicle  is  broken,  as  it  usually  is,  by  a  counter-stroke,  the  force  of  the 
blow,  conveyed  from  the  shoulder  through  the  outer  portion  of  the 
bone,  is  suddenly  arrested,  and  expends  itself  upon  the  point  where 
the  direction  of  the  axis  is  changed. 

In  a  record  of  eighty-nine  fractures,  including  partial  and  commi- 
nuted, the  latter  of  which  have  always  been  broken  twice,  sixty-six 
have  occurred  through  the  middle  third,  and,  with  the  exception  of 
the  partial  fractures,  the  fracture  has  in  nearly  all  of  the  cases  taken 
place  near  the  outer  end  of  this  third.  Three  have  occurred  through 
the  inner  third,  two  of  which  were  within  one  inch  of  the  sternum ; 
and  twelve  through  the  outer  third. 

A  more  practical  analysis  can  be  based,  however,  upon  the  point  of 
fracture  with  reference  to  its  cause;  and  I  have  never  seen  a  complete 
fracture  of  this  bone  produced  clearly  by  a  counter-stroke,  which  was 
not  near  the  outer  end  of  the  middle  third. 

When  the  fracture  is  at  this  point,  or  in  any  portion  of  the  middle 
third,  the  direction  of  the  displacement  is  almost  uniformly  the  same. 
The  sternal  fragment  is  slightly  lifted 
by  the  action  of  the  clavicular  portion 
of  the  sterno-cleido  mastoid  muscle, 
notwithstanding  the  resistance  of  the 
rhomboid  ligament,  and  the  subcla- 
vian muscle.  On  the  other  hand,  the 
acromial  fragment  is  dragged  down- 
wards by  the  weight  of  the  arm,  aided 
by  the  conjoined  action  of  a  portion 
of  the  pectoralis  major  and  the  latis- 
simus  dorsi,  feebly  resisted  by  the 
trapezius  and  other  muscles  from 
above ;  by  the  action  of  the  same 
muscles,  aided  by  the  pectoralis  mi- 
nor, and  perhaps  by  some  portion  of 
the  subclavius,  it  is  drawn  toward 
the   body,  diminishing   thereby  the 

axillary  space,  while  by  the  preponderating  strength  of  the  pectoralis 
major  and  minor,  the  acromial  end  of  the  fragment,  with  the  shoulder, 
is  drawn  forwards;  the  sternal  end  of  the  same  fragment  being  rather 
displaced  backwards,  and  at  the  same  time  resting  at  a  point  some- 
what elevated  above  its  acromial  end. 

Desault  has  recorded  one  example  of  an  overlapping  by  the  eleva- 
tion of  the  acromial  fragment  over  the  sternal ;'  and  Bichat  remarks, 
that  Hippocrates  speaks  of  the  phenomenon  as  a  thing  which  was 
familiar  to  him.  Syme  has  mentioned  a  case  of  this  kind  which  he 
had  seen.^     Gueretin,  Malgaigne,^  and  Stephen  Smith,  have  each  re- 


Complete  oblique  fracture,  near  the  middle 
of  the,  clavicle. 


'  Desault  on  Frac,  op.  cit.,  p.  16. 
^  Malgaigne,  p.  461. 


2  Amer.  Journ.  Med.  Sci.,  vol.  xvii.  p.  251. 


182  FEACTURES    OF    THE    CLAVICLE. 

ported  an  example.'  In  Stephen  Smith's  case,  the  fracture  occurred 
in  a  man  thirty-eight  years  old.  The  bone  was  broken  through  the 
outer  third,  and  transversely.  He  was  treated  at  the  Bellevue  Hos- 
pital, but  the  overlapping,  to  the  extent  of  one  inch,  remained  after 
the  cure  was  completed. 

In  nearly  all  the  cases  of  oblique  fractures  occurring  through  the 
middle  third,  there  follows  immediately  an  overlapping,  varying  from 
one-quarter  of  an  inch  to  an  inch,  and  sometimes,  though  very  rarely, 
exceeding  this.  There  is  a  specimen  in  the  Dupuytren  Museum,  in 
which  the  shortening  equals  one-third  of  its  entire  length. 

Transverse  fractures,  wherever  they  may  occur,  are  not  so  constantly 
found  displaced,  at  least  in  the  direction  of  the  axis  of  the  bone,  as  the 
following  examples  will  illustrate : — 

An  old  lady,  aged  eighty  years,  fell  down  a  flight  of  stairs,  break- 
ing the  right  clavicle  transversely,  about  one  inch  from  the  sternum. 
I  saw  her,  with  Dr.  Trowbridge,  on  the  day  following  the  accident. 
Motion  and  crepitus  were  distinct,  but  there  was  scarcely  any  dis- 
placement. No  dressings  were  applied,  but  she  was  directed  to  keep 
quiet  in  bed,  and  upon  her  back.  In  the  usual  time  the  fragments 
had  united,  without  deformity. 

A  man  about  forty  years  old,  fell  backwards  from  a  wagon,  break- 
ing the  collar  bone  near  the  middle.  The  fragments  were  movable, 
but  not  displaced.  He  was  treated  successfully  and  without  any  re- 
sulting deformity,  by  simple  confinement  in  the  recumbent  posture 
during  a  few  days,  and  after  this  by  suspending  the  arm  in  a.  sling, 
while  he  was  permitted  to  walk  about. 

A  young  man,  aged  twenty-six,  fell  while  wrestling,  and  broke  the 
clavicle  at  the  outer  end  of  the  middle  third.  There  was  some  dis- 
placement at  first,  but  the  fragments  being  reduced,  were  found  to 
support  themselves.  A  cross,  secured  with  straps,  was  applied  to  the 
back,  and  on  the  twenty-eighth  day  the  union  was  complete,  and 
without  deformity. 

A  child,  aged  three  years,  fell  about  six  feet,  striking  upon  his 
shoulder.  He  was  sent  to  me  on  the  same  day,  by  Dr.  G.  Burwell. 
I  found  the  left  clavicle  broken  off  completely,  about  one  inch  from  its 
scapular  end.  Crepitus  and  motion  were  distinct,  but  the  fragments 
were  not  displaced.  The  arm  was  placed  in  a  sling,  and  on  the  seventh 
day  both  motion  and  crepitus  had  ceased.  The  cure  was  accomplished 
without  any  degree  of  displacement. 

The  example  of  a  fracture  from  muscular  action,  already  mentioned 
as  having  been  seen  by  me,  was  also  probably  transverse,  and  union 
has  occurred  without  treatment  and  without  displacement. 

Stephen  Smith,  of  New  York,  has  met  with  two  examples  of  trans- 
verse fractures  without  displacement,  in  a  hospital  record  of  eleven 
cases.  Bichat  says  Desault  has  frequently  observed  the  same,  it 
having  been  seen  three  times  at  Hotel  Dieu,  in  the  course  of  the  year 
1787.^     Desault  thinks,  also,  that  sometimes  the  fracture,  taking  place 

'  N.  Y.  Journ.  of  Med.,  May,  1857. 
^  Desault  on  Fractures,  op.  cit.,  p.  15. 


FRACTUEES    OF    THE    CLAVICLE.  183 

obliquely  up-wards  and  inwards,  the  usual  form  of  displacement  is  pre- 
vented, and  apposition  is  preserved. 

If  the  fracture  is  near  the  sternum,  and  within  the  fibres  of  the 
costoclavicular  ligaments,  as  in  the  case  of  the  old  lady  just  cited, 
the  displacement  is  inconsiderable.  I  have  seen  one  other  similar 
case  in  an  adult  also.  Lonsdale  mentions  a  case  in  a  child,  three  years 
old,  which  came  under  his  observation  in  Middlesex  hospital,^  which 
he  regarded  as  a  separation  of  the  epiphysis;  this  bone,  however,  has 
no  epiphysis,  properly  speaking,  being  formed  entire  from  a  single 
point  of  ossification.  ^lalgaigne  mentions  two  other  examples,  in 
one  of  which  the  fracture  was  so  near  the  sternum  that  it  was  difficult 
to  say  whether  it  was  not  a  partial  dislocation.  The  displacement 
was  only  trivia].^  But  the  only  two  specimens  contained  in  the  Du- 
puytren  Museum  offer  a  considerable  displacement,  and  in  both  the 
external  fragment  is  thrown  downwards  and  forwards. 

With  regard  to  the  amount  of  displacement  usually  attendant  upon 
fractures  near  the  outer  end  of  the  bone,  surgical  writers  have  gene- 
rally united  in  declaring  that  it  was  in  a  majority  of  cases  very  incon- 
siderable, while  some  have  even  affirmed  that  there  would  be  found  no 
displacement  whatever;  neither  of  which  opinions,  according  to  the 
recent  observations  of  Eobert  Smith,  of  Dublin,  is  strictly  correct. 
He  has  examined  eight  specimens  of  fracture  of  the  outer  extremity 
of  the  clavicle,  contained  in  the  museum  of  the  Richmond  Hospital 
School  of  Medicine;  three  of  which  were  broken  between  the  conoid 
and  trapezoid  ligaments,  and  are  united  with  very  little  displacement, 
while  the  remaining  five,  broken  beyond  the  trapezoid  ligament  pre- 
sent a  very  marked  deformity. 

The  following  is  a  summary  of  the  conclusions  to  which  he  has 
arrived : — 

"  When  the  clavicle  is  broken  between  the  two  fasciculi  of  the 
coraco-clavicular  ligament,  there  is  seldom  any  displacement  of  either 
fragment,  and  always  much  less  than  in  fracture  of  any  other  portion  of 
the  bone.  When  displacement  does  occur,  it  is  usually  limited  to  a 
slight  alteration  in  the  direction  of  the  bone,  by  which  the  natural 
convexity  of  this  portion  of  the  clavicle  is  increased. 

"  The  explanation  of  which  facts  is  found  in  the  attachments  of  the 
ligaments  from  below  to  the  two  fragments;  and,  in  the  action  of  the 
trapezius  from  above,  by  which  they  are  antagonized. 

"But  the  case  is  very  difi'erent  when  the  bone  is  broken  external  to 
the  trapezoid  ligament.     Here  the  coraco-clavi- 
cular ligaments  can   have  no  direct  influence  Fig-  37. 
upon  the  outer  fragment,  which  is  displaced 
now  partly  by  muscular  action,  and  partly  by 
the  weight  of  the  arm,  the  sternal  end  of  the  outer 
fragment  being  drawn  upwards  by  the  clavicu- 
lar portion  of  the  trapezius,  while,  by  the  action 
of  the  muscles  passing  from  the  chest,  the  entire       Fractnre  outside  of  trapezoid 
outer  fragment  is  drawn  forwards  and  inwards,    ligament,  rnited. 

■  Lonsdale  on  Fractures,  p.  206.  ^  Malgaigne,  op.  cit.,  p.  491. 


184  FEACTURES    OF    THE    CLAVICLE. 

SO  as  to  bring  sometimes  its  broken  surface  into  contact  with  the  ante- 
rior surface  of  the  inner  fragment,  and  placing  it  nearly  at  right  angles 
with  this  fragment,  in  which  position  it  is  generally  united.  The  dis- 
placement in  this  direction,  rather  than  any  degree  of  overlapping, 
explains  also  the  shortening  which  existed  in  all  of  these  cases,  varying 
in  the  diflerent  specimens  from  half  an  inch  to  one  inch,  and  averaging 
about  three  quarters  of  an  inch." 

Such  are  the  views  of  Mr.  Smith;  and  I  see  no  reason  to  call  in 
question  their  correctness.  In  my  own  experience,  a  fracture  occur- 
ring in  a  child  three  years  old,  within  one  inch  of  the  acromial  end, 
probably  between  the  ligaments,  was  never  displaced  at  all ;  a  second, 
occurring  somewhere  in  the  outer  third,  presented,  after  many  years, 
no  displacement.  Two  recent  cases  were  displaced  each  one  quarter 
of  an  inch,  and  one  old  case,  half  and  inch ;  these  three  latter  cases 
occurred  in  adults,  and  always  within  an  inch  of  the  acromial  end  of  the 
bone.  In  one  of  these  last  examples,  the  inner  fragment  was  rather 
behind  than  above  the  outer  fragment. 

But  it  would  be  unsafe  to  draw  conclusions  from  an  experience 
which  is  confined  entirely  to  living  examples,  and  in  which  no  dissec- 
tions have  been  made,  to  verify  the  exact  point  of  fracture,  or  the  pre- 
cise amount  and  character  of  the  displacement.  So  far  as  they  go, 
however,  they  seem  to  me  to  confirm  the  general  correctness  of  the 
observations  made  by  Robert  Smith. 

It  has  happened  to  me  only  six  times  to  meet  with  a  comminuted 
fracture  of  the  clavicle,  all  of  which  fractures  occurred  through  some 
portion  of  the  middle  third  of  the  bone;  the  intercepted  fragments 
being  from  one  inch  to  one  inch  and  a  half  in  length,  and  lying  ob- 
liquely, or,  as  in  one  case  observed  by  me,  at  nearly  a  right  angle  with 
the  main  fragments. 

I  have  never  seen  a  compound  fracture  of  this  bone,  although,  in 
many  cases,  the  sharp  point  of  an  oblique  fracture  has  seemed  just 
ready  to  penetrate  the  skin.  One  case  is  reported  as  having  been 
presented  at  St.  Bartholomew's  Hospital.  It  occurred  in  a  boy  four- 
teen years  old,  and  was  produced  by  his  having  been  drawn  into  some 
machinery  while  it  was  in  motion.^ 

Lente  also  mentions  a  case,  seen  by  himself,  occasioned  by  the  fall 
of  a  derrick  upon  the  shoulder.  The  patient,  twenty-four  years  old, 
was  admitted  into  the  New  York  Hospital  in  August,  18-±8.  The  left 
clavicle  was  broken  at  about  its  middle,  and  a  large  wound  in  the 
integuments  communicated  with  the  fracture.  The  fragments  united 
firmly  in  about  six  weeks,  after  several  pieces  of  bone  had  been  dis- 
charged from  the  wound.^ 

Ayers  mentions  another  case,  the  result  of  a  severe  gunshot  acci- 
dent, in  which  the  bone  was  also  very  much  comminuted.^ 

A  double  fracture,  or  a  simultaneous  fracture,  occurring  in  both 
clavicles,  seldom  occurs.  I  have  recorded  two  cases  {four  fractures^ 
three  of  which  are  incomplete),  both  occurring  in  young  boys."* 

'  London  Med.  Gaz.,  voL  ii.  p.  382.        2  Lente,  N.  Y.  Journ.  of  Med.,  July,  1850. 
^  Ayres,  ibid.,  Jan.,  1857.  ^  Rep.  on  Def.  after  Frac,  Cases  5,  6,  10. 


FRACTUEES    OF    THE    CLAVICLE. 


185 


Malgaigne  says  it  has  only  happened  to  him  to  see  it  once  in  2,358 
cases,  at  the  Hotel  Dieu,  and  he  can  recollect  only  five  other  examples. 
And  of  158  cases  of  broken  clavicles  reported  from  the  Xew  York 
Hospital,  it  is  stated  to  have  occurred  in  only  four.  These  gentlemen, 
however,  only  report  hospital  cases,  and  they  have  reference,  doubt- 
less, to  complete  fractures;  while  double  fractures,  according  to  my 
experience,  occur  more  often  in  children  than  in  adults,  and  are  of  the 
character  of  partial  fractures,  without  usually  much  displacement ; 
which  facts,  if  sustained  by  subse- 
quent observations,  would  suffi- 
ciently explain  their  infrequency 
in  hospital,  and  their  relative 
frequency  in  private  experience. 

Sym'pioras. — In  all  cases  of  com- 
plete fracture  with  displacement, 
no  difficulty  will  be  experienced 
in  deciding  upon  the  nature  of 
the  injury. 

The  patient  is  found  generally 
leaning  toward  the  injured  side, 
while  the  opposite  hand  sustains 
the  elbow  of  the  same  side,  to 
prevent  its  dragging  downwards. 

The  shoulder  falls  downwards, 
forwards,  and  inwards ;  while,  at 
the  same  time,  the  line  of  the 
bone  is  interrupted  by  the  sharp 
and  projecting  point  of  the  ster- 
nal fraarment. 

If  the  fracture  is  the  result  of  a  direct  blow,  a  swelling  and  dis- 
coloration may  be  seen  at  the  seat  of  fracture,  but  if  it  is  the  result  of 
a  counter-stroke,  we  must  look  to  the  top  or  point  of  the  shoulder  for 
the  signs  of  a  contusion. 

The  patient  also  experiences  pain  when  an  attempt  is  made  to  raise 
the  arm  at  a  right  angle  with  the  body,  and  especially  in  attempting 
to  carry  the  arm  across  the  body,  by  which  the  ends  of  the  broken 
clavicle  are  driven  into  the  flesh.  In  two  cases  (cases  19  and  50  of 
my  Eeport  on  Deformities)  of  oblique  fracture,  accompanied  with  dis- 
placement, occurring  in  the  middle  third  of  the  bone,  I  have  particu- 
larly noticed  that  the  patients  could  easily  lift  the  hands  to  the  head, 
and  in  one  of  these  cases  the  patient,  a  boy,  fourteen  years  old,  raised 
his  arm  perpendicularly  over  his  head.  Such  exceptions  are  not  very 
uncommon. 

Crepitus  can  be  detected  sometimes  by  simply  pressing  down  the 
sternal  fragment,  but  it  is  almost  always  present  when  we  draw  the 
shoulders  forcibly  back,  so  as  to  bring  the  broken  fragments  into  more 
perfect  contact. 

If  there  is  no  displacement,  still  crepitus  may  generally  be  discovered 
by  grasping  the  bone  between  the  thumb  and  fingers,  and  moving  it 
gently  up  and  down,  or  by  slight  pressure  upon  the  point  of  fracture. 


Complete  FBAcrrBE. — Oblique;  at  outer  end  of  the 
inner  two-thirds.     (From  nature.) 


186  FEACTUEES    OF   THE    CLAVICLE. 

When  the  fracture  occurs  close  to  the  acromial  extremity,  external 
to  the  coraco-clavicular  ligaments,  although  according  to  Robert 
Smith,  there  is  usually  considerable  derangement,  yet  it  is  not  accom- 
panied with  a  corresponding  amount  of  external  deformity,  and  its 
diagnosis  will  require,  therefore,  more  care  and  attention  on  the  part 
of  the  surgeon. 

Prognosis  in  this  fracture  deserves  especial  attention.  In  no  other 
bone,  except  the  femur,  does  a  shortening  so  uniformly  result.  Of 
sixty-one  complete  fractures  only  fifteen  united  without  shortening ; 
and  of  twenty  simple,  oblique,  complete  fractures,  which  occurred  at 
or  near  the  outer  end  of  the  middle  third,  only  one  united  without 
shortening  (Case  46  of  my  Report),  and  in  this  case  the  patient  was 
but  fifteen  years  old,  and  the  fragments  were  never  much  displaced; 
nor  can  I  say  that  the  treatment,  a  board  across  the  back  after  the 
manner  of  Keckerly,  had  anything  to  do  with  the  result.  Five  cases 
of  complete  transverse  fracture,  occurring  at  the  same  point,  united 
without  shortening. 

The  shortening  varies  from  one-quarter  of  an  inch  to  one  inch,  or 
more,  and  the  fragments  are  almost  always,  especially  when  the  frac- 
ture is  through  the  middle  third,  found  lying  in  the  position  in  which 
we  have  described  them  to  be  at  the  first — the  outer  end  of  the  inner 
fragment  being  above,  and  often  a  little  in  front  of  the  outer:  some- 
times, especially  in  lean  persons,  and  when  the  fracture  is  very  ob- 
lique, presenting  a  sharp  and  unseemly  projection. 

The  greatest  amount  of  shortening  is  generally  found  in  those  frac- 
tures which  occur  through  the  middle  third ;  in  fractures  near  the 
sternal  end  there  is  usually  very  little  permanent  displacement;  the 
same  is  true  when  the  fracture  is  at  the  acromial  end,  and  between 
the  coraco-clavicular  ligaments,  as  the  observations  of  Robert  Smith, 
already  quoted,  have  sufficiently  established,  but  if  the  fracture  is 
beyond  these  ligaments,  the  final  displacement  and  deformity  may  be 
very  great. 

The  presence  of  a  small  amount  of  ensheathing  callus  soon  after 
the  cure  is  completed,  sometimes  increases  the  deformity.  It  is  rarely 
seen  to  encircle  the  bone  completely,  but,  if  present,  it  appears  to  be 
most  abundant  in  the  direction  of  the  salient  points  of  the  fracture, 
that  is,  above  and  below ;  so  that,  unless  the  examination  is  made  with 
care,  the  projecting  points  of  callus  which  remain,  sometimes  after 
many  years,  may  be  easily  mistaken  for  an  intercepted  fragment  turned 
at  right  angles  to  the  axis  of  the  bone.  In  the  case  of  partial  fracture, 
reported  by  Dr.  Green,  a  similar  circumstance  was  observed,  which  his 
natural  shrewdness  soon  enabled  him  to  explain.^ 

Robert  Smith  has  observed,  also,  that  in  cases  of  fracture  external 
to  the  conoid  ligament,  osseous  matter  is  freely  formed  upon  the  under 
surface  of  each  fragment,  but  there  is  seldom  any  deposited  upon  the 
upper  surface  of  either.  These  osseous  growths,  occupying  the  situa- 
tion of  the  coraco-clavicular  ligaments,  frequently  prolong  themselves 
as  far  as  the  coracoid  process,  and  in  some  cases  to  the  notch  of  the 

'  Transac.  of  Amer.  Med.  Assoc,  for  1855,  Case  13  of  Frac,  of  Clavicle.  , 


FRACTURES    OF    THE    CLAVICLE. 


187 


Fi-.  39. 


scapula.     Still  less  frequently  these  osteophytes  become  fused  with  the 
coracoid  process,  and  a  true  anchylosis  exists. 

In  comminuted  fractures  the  intercepted  fragments  generally  fall 
off  from  the  line  of  the  other  fragments,  and  cannot  easily  be  restored. 

The  clavicle  being  a  spongy  and  vascular  bone,  usually  unites  with 
great  rapidity,  generally  within  twenty  days.  In  the  fourth  example 
of  transverse  fracture  already  men- 
tioned as  having  been  seen  by  me, 
the  union  seemed  to  be  tolerably 
firm  in  seven  days.  "Wallace  re- 
ports one  case  from  the  Pennsylva- 
nia Hospital,  W'hich  was  cured  in 
eight  days,  and  another  in  nine 
days.-'  Yelpeau  says  the  clavicle 
will  unite  in  from  fifteen  to  twenty- 
five  days;  Benjamin  Bell,  in  four- 
teen :  Stephen  Smith  has  seen  it 
firm  in  fifteen  days. 

\Yhatever  may  be  the  desrree  of 
displacement,  or  the  condition  of 
the  system,  it  is  very  seldom  that 
it  refuses  to  unite  altogether  or  that 
the  union  is  ligamentous:  and  in 
the  few  cases  found  upon  record  of 
a  ligamentous  union,  the  functions 
of  the  arm  do  not  seem  to  have 
suffered  any  serious  ultimate  injury, 

as  the  following  example,  and  the  only  one  which  has  come  under  my 
observation,  will  illustrate  : — 

Edmund  Nugent,  a  stout  Irish  laborer,  now  twenty-five  years  old, 
was  received  into  the  Buffalo  Hospital  of  the  Sisters  of  Charity,  in 
March,  1854,  He  states  that  several  years  before,  he  fell  from  a  horse 
and  broke  his  left  clavicle,  at  the  outer  end  of  the  middle  third.  This 
was  near  Cork,  in  Ireland,  and  without  consulting  any  surgeon  or 
"handy  man,"  he  continued  at  work,  holding  the  tail  of  the  plough, 
nor  from  that  day  forward  did  he  employ  a  surgeon,  or  dress  his  arm, 
or  cease  from  his  work. 

The  clavicle  presents  now  the  same  deformity  which  nearly  all  other 
similar  fractures  present  after  what  is  usually  termed  successful  treat- 
ment, except  that  it  is  not  united  by  bone.  The  outer  end  of  the  inner 
fragment  rides  upon  the  inner  end  of  the  outer  fragment  half  an  inch. 
The  ligament  uniting  the  two  extremities  is  so  long  and  firm  that  it 
can  be  distinctly  felt,  and  the  fragments  may  be  moved  upon  each 
other  with  great  freedom. 

In  order  that  we  might  determine  the  amount  of  injury  which  he 
had  suffered  from  the  ligamentous  union,  we  directed  him  to  lift  weights 
placed  on  a  table  before  him,  while  he  was  seated  upon  a  chair.  We 
ascertained  from  this  experiment  that  with  his  left  arm  he  could  lift 


CoicMxsrTED    FKAcrrEE. — rnited. 
ture.) 


(From    na- 


'  Am.  Journ.  Med.  Sci.,  vol.  svi.  p.  115. 


188  FEACTUEES    OF    THE    CLAVICLE. 

as  much,  within  three  ounces,  as  he  could  with  his  right,  and  he  was 
not  himself  conscious  of  any  difference.  The  muscles  of  the  left  arm 
seemed  as  well  developed  as  those  of  the  right. 

Chelius  also  refers  to  two  cases  mentioned  by  Gurdy  and  Velpeau, 
in  which,  although  an  artificial  joint  remained,  the  use  of  the  limb  was 
but  little  impaired.^ 

Fergusson  "once  had  occasion  to  remove  various  portions  of  this 
bone,  which  had  become  necrosed  in  consequence  of  neglected  treat- 
ment. The  patient,  about  twenty  years  of  age,  had  the  right  collar 
bone  broken  by  the  fall  of  a  tree ;  not  knowing  the  nature  of  the 
injury,  he  worked  as  a  reaper  for  several  hours  after;  violent  inflam- 
mation, suppuration,  and  necrosis  followed ;  but  after  the  dead  pieces 
were  removed  he  made  a  rapid  and  excellent  recovery."^ 

In  the  case  of  compound  and  comminuted  gunshot  fracture  reported 
by  Ayres,  of  New  York,  and  already  referred  to,  the  recovery  was 
remarkable.  The  man  was  sixty-two  years  old,  and  in  excellent  health 
when  the  injury  was  received.  The  clavicle  was  so  extensively  com- 
minuted that  before  the  wound  closed  over  one-third  of  the  bone  had 
escaped,  and  yet  at  the  end  of  one  year  from  the  time  of  the  accident 
the  shoulder  was  perfectly  symmetrical  with  its  fellow,  without  droop- 
ing or  falling  forwards.  Dr.  Ayres  thinks  that  all  of  the  clavicle 
which  was  lost  has  been  reproduced. 

A  partial  paralysis,  with  atrophy  of  the  muscles  of  the  arm,  accom- 
panied, also,  with  more  or  less  rigidity  and  contraction  of  the  muscles, 
both,  of  the  arm  and  forearm,  is,  according  to  my  observation,  a  more 
frequent  result  of  these  fractures. 

Mr.  Earle  has  recorded  a  case  of  comminuted  fracture  of  the  clavicle, 
in  which  the  nerves  converging  to  form  the  axillary  plexus  were  so 
much  injured  that  paralysis  of  the  arm  ensued ;  and  it  was  noticed  as 
an  interesting  fact,  that  the  patient  could  not  afterwards  put  her  hand 
into  even  moderately  warm  water  without  the  effects  of  a  scald  being 
produced,  characterized  by  vesications,  redness,  etc.^ 

Desault  saw  a  case  at  Hotel  Dieu,  in  which,  although  the  clavicle 
was  not  broken,  the  force  of  the  blow  upon  the  clavicle  was  sufficient 
to  produce  a  severe  concussion  of  the  brachial  plexus,  and  paralysis 
of  the  arm.  A  timber  had  fallen  from  a  building,  striking  upon  the 
external  part  of  the  left  clavicle.  A  considerable  wound,  followed  by 
swelling,  pointed  out  the  place  on  which  the  blow  had  been  received. 
No  apparatus  was  applied,  and  on  the  third  day  a  numbness  and  par- 
tial loss  of  the  power  of  motion  occurred  in  the  arm  of  the  affected 
side.  Soon  afterward  an  insensibility  came  on,  and  by  the  seventh 
day  the  paralysis  of  the  arm  was  complete.  It  was  not  until  after  a 
tedious  treatment  that  the  limb  recovered  in  part  its  original  strength." 

In  Case  23  of  my  report  to  the  American  Medical  Association,  which 
was  followed  by  paralysis  of  the  opposite  arm,  and  spinal  curvature, 
these  results  were  probably  due  to  some  injury  of  the  back  received 

'  Chelius,  Amer.  ed.,  voL  i.  p.  603. 

2  Fergusson,  System  of  Practical  Surgery.     Amer.  ed.,  p.  215. 
^  S.  Cooper's  First  Lines,  fourth  Amer.  ed.,  vol.  ii.  p.  323. 
*  Desault  on  Frac.  and  Disloc,  Amer.  ed.,  14,  1805. 


FRACTURES    OF    THE    CLAVICLE.  189 

at  the  time  of  the  accident ;  but  one  cannot  avoid  a  suspicion  that  the 
apparatus,  Brasdor's  jacket,  contributed  somewhat  to  the  unfortunate 
result.  Ko  axillary  pad  was  employed,  but  the  straps  over  each 
shoulder  were  buckled  so  tight  that  he  was  compelled  to  incline  his 
head  constantly  to  the  right  side.  He  was  unable  to  lie  down,  and 
could  only  recline  in  a  half  sitting  posture.  This  treatment  was  con- 
tinued four  weeks ;  and  two  months  after  its  removal  the  paralysis 
and  spinal  distorsion  commenced. 

In  Case  88,  also,  of  the  same  report,  a  comminuted  fracture,  paralysis 
with  contraction  of  the  muscles  extending  to  the  wrist  and  fino-ers,  ex- 
isted,  but  whether  it  was  due  to  the  severity  of  the  original  injury  or 
to  the  treatment,  could  not  be  satisfactorily  ascertained. 

Gibson  relates  a  remarkable  instance  of  this  kind.  A  young  man 
was  struck  on  the  clavicle  by  the  falling  limb  of  a  tree,  breaking  it  into 
numerous  pieces,  and  bruising  the  parts  so  severely  as  to  give  rise  to 
violent  inflammation.  "  The  fragments  had  been  driven  behind  and 
beneath  the  level  of  the  first  rib,  and  so  compressed  the  plexus  of 
nerves  as  to  wedge  them  into  each  other,  and  by  the  subsequent  in- 
flammation to  blend  them  inseparably  together.  Complete  paralysis 
and  atrophy  of  the  whole  arm  ensued,  and  the  patient's  object  in  visit- 
ing Philadelphia  was  to  submit  to  an  operation,  in  hopes  of  elevating 
the  clavicle  to  its  natural  height,  and  taking  oflf  pressure  from  the 
nerves."  Dr.  Gibson,  however,  did  not  believe  that  the  prospect  of 
success  was  sufficient  to  warrant  the  operation,  and  the  young  man 
was  sent  home.^ 

Lizars  says  the  callus  is  sometimes  secreted  so  profusely,  as  by 
pressing  upon  the  brachial  plexus,  to  render  the  arm  paralytic  for  a 
time ;  and  he  affirms  that  as  a  consequence  of  this  pressure  he  has 
seen  it  remain  in  this  condition  three  months.  The  statement,  how- 
ever, is  made  in  a  manner  too  vague,  and  needs  confirmation. 

It  will  not  do  to  deny,  therefore,  the  possibility  of  a  paralysis  as 
resulting  from  a  concussion  of  the  axillary  nerves,  produced  by  a  blow 
upon  the  clavicle,  nor  of  a  paralysis  resulting  from  a  direct  injury  in- 
flicted by  the  points  of  the  fragments  upon  this  plexus  in  certain  very 
badly  comminuted  fractures;  but  it  is  certain  that  these  conditions 
will  not  satisfactorily  explain  all  of  the  otlier  examples  in  which 
paralysis  has  followed  simple  fractures.  In  some  cases  it  is  no  doubt 
due  rather  to  the  injudicious  mode  of  using  an  axillary  pad,  by 
means  of  which  the  arm  is  converted  into  a  powerful  lever,  and  thus 
the  brachial  nerves  are  made  to  suffer  from  compression  along  the 
inner  side  of  the  arm  itself.  In  short,  it  must  be  confessed  that  it  is 
sometimes  due  to  the  treatment  alone,  and  not  to  the  original  injury. 

Parker,  of  Xew  York,  in  a  note  to  the  edition  of  S.  Cooper's  Sur- 
gery, just  quoted,  declares  that  he  has  seen  one  patient  who  had  lost 
the  use  of  his  arm  from  the  pressure  upon  the  nerves  by  the  wedge- 
shaped  pad,  over  which  the  limb  was  confined,  in  order  to  pry  the 
shoulder  outwards.  Stephen  Smith  mentions  a  case  of  partial  para- 
lysis from  the  same  cause.^ 

'   Gibson,  op.  cit.,  vi.  p.  271.  ^  New  York  Journal  of  Medicine,  May,  1857. 


190  FEACTURES    OF    THE    CLAVICLE. 

A  similar  case  has  come  under  my  own  observation.  A  lady,  aged 
fifty-one  years,  waa  thrown  from  her  carriage,  breaking  the  right 
clavicle  obliquely  at  the  outer  end  of  the  middle  third.  During  the 
first  three  weeks  the  arm  was  dressed  with  Fox's  apparatus,  which 
was  at  no  time  particularly  painful.  She  was  then  placed  under  the 
care  of  another  surgeon,  who,  finding  the  fragments  overlapped,  ap- 
plied very  firmly  a  figure-of-8  bandage,  with  an  axillary  pad,  securing 
the  arm  snugly  to  the  side  of  the  body ;  hoping  by  these  means  to 
restore  the  fragments  to  their  place.  The  pain  which  followed  was 
excessive,  and  notwithstanding  the  free  use  of  anodynes,  it  became  so 
insupportable  that  at  the  end  of  fourteen  hours  the  dressings  were 
removed  by  another  surgeon,  and  Fox's  apparatus  again  substituted. 
These  were  also  applied  much  more  snugly  than  at  first,  and  during 
the  four  weeks  longer  that  they  remained  on,  repeated  attempts  were 
made  to  reduce  the  fragments. 

Forty-eight  days  after  the  accident,  she  consulted  me.  The  clavicle 
was  then  united,  and  overlapped  half  an  inch.  The  whole  arm  was 
swollen,  painful,  and  very  tender,  with  total  inability  to  move  it. 

I  removed  all  the  dressings,  and,  during  the  time  she  remained 
under  my  care,  in  a  private  room  at  the  hospital,  there  was  a  gradual 
improvement  in  the  condition  of  her  arm,  in  respect  to  swelling  and 
tenderness,  but  the  paralysis  did  not  much  abate, 

Erichsen  thinks  he  has  seen  one  case  of  comminuted  fracture,  pro- 
duced by  a  direct  blow,  in  which  the  subclavian  artery  was  ruptured ; 
great  extravasation  of  blood  resulted,  and  the  arm  was  threatened 
with  gangrene.  The  patient  having  recovered,  however,  the  diagnosis 
could  not  be  determined  by  actual  dissection.' 

Since  among  surgeons  some  difference  of  opinion  seems  to  exist  as 
to  the  practicability  of  overcoming  the  displacement  in  certain  frac- 
tures of  the  clavicle,  it  is  proper  that  I  should  defend  the  accuracy  of 
my  own  observations  by  a  reference  to  the  observations  of  others. 

In  nine  of  eleven  cases  reported  by  Stephen  Smith,  one  of  the  sur- 
geons at  Belle vue  Hospital,  New  York,  more  or  less  deformity  re- 
mained after  the  cure  was  completed.  In  the  two  remaining  cases  the 
actual  results  are  unknown.^ 

"  Great  difficulty  has  been  experienced  in  treating  this  fracture."^ 

"  The  indications  of  treatment  are  plain,  but,  unfortunately,  not 
very  easily  fulfilled."^ 

"  Fractures  of  the  clavicle  will  often  cause  greater  trouble  than  those 
which  are  considered  of  a  more  serious  character,  and  the  utmost  pains 
will  not,  on  all  occasions,  suffice  to  prevent  a  slight  prominence  of  the 
inner  fragment."* 

"Setting  of  this  fracture  is  easy,  yet  only  in  very  rare  cases  is  the 
cure  possible  without  any  deformity.'"* 

'  Erichsen,  Surgery,  Amer.  ed.,  p.  205. 

2  New  York  Journ.  Med.,  May,  1857,  p.  382. 

"  Syme's  Principles  of  Surgery,  p.  266,  Philadelphia  ed.,  1832. 

*  Miller's  Practice  of  Surgery,  3d  Amer.  ed.  from  2d  Edinburgh,  p.  309. 

^  Practical  Surgery.     By  Wm.  Fergusson.     4th  Amer.  ed.,from  3d  London,  p.  215. 

^  System  of  Surgery.  By  J.  M.  Chelius,  of  Heidelberg,  with  notes  by  South.  First 
Amer.  ed.,  vol.  i.  p.  603. 


FRACTUEES  OF  THE  CLAVICLE. 


191 


Fig.  40. 


"  Tt  is  considererl,  also,  that  the  close  union  of  the  fracture  of  the 
collar  bone  depends  less  on  the  apparatus  than  on  the  position  and 
direction  of  the  fracture; 
(therefore,  in  spite  of  the 
most  careful  application  of 
this  apparatus,  some  defor- 
mity often  remains.")' 

The  following  statements 
of  M.  Velpeau  are  found  in 
a  letter  addressed  to  the 
editor  of  the  Boston  Medical 
and  Surgical  Journal^  by  J. 
Willis  Fisher,  dated  Paris, 
Sept.  16th,  1846. 

Mr.  Fisher  remarks  that 
the  report  is  drawn  in  part 
from  his  own  notes,  and 
partly  from  "the  report  pub- 
lished in  the  Oazette  des 
Hopitauxr  It  is  the  an- 
nual summary  of  M.  Vel- 
peau's  practice  at  La  Charity 
for  the  year  ending  Sept. 
1846. 

"  The  fractures  of  the  cla- 
vicle, less  numerous  than 
ordinarily,  have  been  only 
four.  They  have  proved 
these  three  often  repeated 
propositions:      First,     that 

contrary  to  the  general  opinion,  the  patients  can  carry  the  hand  to  the 
head  when  they  have  a  fractured  clavicle.  Secondly,  that  the  consoli- 
dation of  the  bones  demands  only  from  fifteen  to  twenty-five  days,  and 
not  six  weeks  or  two  months.  Thirdly,  that  with  all  the  bandage 
imaginable,  we  cannot  prevent  fracture  of  the  two  internal  and  oblique 
thirds  from  leaving  a  deformity."^ 

"  Fracture  of  the  clavicle  is  almost  always  followed  by  deformity, 
whatever  may  be  the  perfection  of  the  apparatus  and  the  care  of  the 
surgeon."^ 

"  Hippocrates  has  observed  that  some  degree  of  deformity  almost 
always  accompanies  the  reunion  of  a  fractured  clavicle;  all  writers 
since  his  time  have  made  the  same  remark ;  experience  has  confirmed 
the  truth  of  it."* 


Velpeau's  dextrine  bandage  ;  no  axillary  pad. 


'  Chelius,  op.  cit.,  voL  i.  p.  605. 

^  Bost.  Med.  and  Surg.  Journ.,  vol.  xxxv.  p.  212.  This  is  evidentlv"  a  misprint. 
Instead  of  "  fracture  of  the  two  internal  and  oblique  thirds,"  the  writer  means  to  say 
an  oblique  fracture  at  the  junction  of  the  two  internal  with  the  outer  thirds. 

*  Vidal  (de  Cassis),  Paris  ed.,  vol.  ii.  p  105. 

*  Treatise  on  Fractures  and  Luxations.  By  J.  P.  Desault.  Edited  by  Xav.  Bichat, 
and  translated  by  Charles  Caldwell,  M.  D.     Philadelphia,  1805,  p.  9. 


192  FRACTUEES    OF    THE    CLAVICLE. 

"As  to  the  reduction  of  this  fracture,  it  must  be  owned  the  same 
is  often  easier  replaced  than  retained  in  its  place  after  it  is  reduced  ; 
for  its  office  being  principally  to  keep  the  head  of  the  scapula,  or 
shoulder,  to  which,  at  one  end,  it  is  articulate,  from  approaching  too 
near,  or  falling  in  upon  the  sternum,  or  breast  bone,  it  happens  that, 
on  every  motion  of  the  arm,  unless  great  care  be  taken,  the  clavicle 
therewith  rising  and  sinking,  the  fractured  parts  are  apt  to  be  distort- 
ed thereby.  Besides,  even  in  the  common  respiration,  the  costae  and 
sternum  aforesaid,  where  the  other  end  of  this  bone  is  adnected,  to- 
gether with  the  motion  of  the  diaphragm,  rising  and  falling,  especially 
if  the  same  be  extraordinary,  as  in  coughing  and  sneezing,  are  able  to 
undo  your  work,  not  to  mention  the  situation  thereof,  less  capable  of 
being  so  well  secured  by  bandage  as  many  others.  All  which,  duly 
considered,  it  is  no  wonder  that  upon  many  of  these  accidents,  although 
great  care  has  been  taken,  these  bones  are  sometimes  found  to  ride, 
and  a  protuberance  is  left  behind,  to  the  great  regret  particularly  of 
the  female  sex,  whose  necks  lie  more  exposed,  and  where  no  small 
grace  or  comeliness  is  usually  placed.'" 

"Eestituitur  facile  tractis  humeris  a  ministro  posterius,  dum  simul 
suo  genu  locato  ad  spinam  dorsi,  dorsum  sustentet  minister,  nam  tunc 
chirurgus  folis  digitis  claviculam  fractam  reponere  potest.  Difficilius 
autem  in  reposita  sede  retinetur^  sed  loca  cava  supra  et  infra  claviculam 
spleniis  implenda."^ 

"The  reduction  of  a  broken  clavicle  is  not  very  hard  to  be  effected, 
especially  when  the  fracture  is  transverse;  nor  is  it  usual  for  the 
humerus,  with  the  fragment  of  the  clavicle,  to  be  so  far  distorted  as 
not  to  be  easily  replaced  with  the  fingers;  hut  the  difficulty  is  much 
greater  to  keep  the  hone  in  its  place  when  the  fracture  is  once  reduced, 
especially  if  the  hone  ivas  hroJcen  ohliquely.^'^ 

Atnesbury,  after  having  exposed  the  inefficacy  of  all  previous  modes 
of  dressing,  and  especially  of  the  figure-of-8  bandage,  Desault's, 
Boyer's,  and  an  apparatus  recommended  by  Sir  Astley  Cooper,  pro- 
ceeds to  describe  his  own  apparatus  and  to  affirm  its  excellence.  It 
is,  however,  not  much  unlike  a  multitude  of  others,  and  is  liable,  I 
have  no  doubt,  to  the  same  objections.     But  the  author  thus  writes: — 

"The  clavicle  bandage,  once  properly  applied,  enables  the  surgeon 
to  resist  the  action  of  all  those  powers  which  tend  to  produce  displace- 
ment, and  puts  the  fractured  bone  entirely  under  his  control,  without 
being  productive  of  any  of  those  evils  which,  I  have  endeavored  to 
show,  arise  from  the  usual  modes  of  treatment.  I  am  not  prepared  to 
say  that  every  fracture  of  the  clavicle,  treated  in  the  manner  which  I 
have  thought  it  expedient  to  advise,  admits  of  being  united  without 
deformity ;  but,  I  am  fully  convinced  that,  if  such  cases  should  occur, 
they  will  be  found  very  rare.  I  have  had  this  bandage  in  use  now 
about  eight  years,  and,  in  the  course  of  this  time,  I  have  used  it  in  a 
large  number  of  cases,  many  of  which  have  occurred  in  the  St.  Thomas 

'  The  Art  of  Surgery,  by  Daniel  Turner,  vol.  ii.  p.  256.     London  ed.,  1742. 

^  .lohannis  de  Gorter  :  Chirurgia  Repurgata,  p.  79.     Lugduni  Batavorum,  1742, 

^  Heister's  Surgery,  vol.  i.  p.  134.     London  ed.,  1768. 


FRACTURES    OF    THE    CLAVICLE. 


193 


Fig.  41. 


Lonsdale's  apparatus  ;  with  axillary  pad. 


Hospital.  The  result  of  these  cases  has  been  very  satisfactory  to  my- 
self, and  to  those  surgeons  by  whom  the  treatment  was  witnessed.'" 

"Tht  direction  the  fracture  takes  is  generally  oblique,  and  in  one 
place  only,  more  particularly  when  it  is  caused  by  the  indirect  force; 
and  this  obliquity  is  one  great  reason  why  it  is  so  difficult  to  treat 
this  kind  of  injury  without  some  slight  deformity  (and  often  a  very 
great  one)  existing  afterwards."  *  -  *  "One  satisfactory  result  in 
the  treatment  of  fracture  of  the  clavi- 
cle is  that,  although  it  is  very  difficult 
to  prevent  deformity  afterwards,  the 
motion  and  free  use  of  the  limb  do  not 
become  much  impaired ;  for  the  bone  is 
often  shortened  an  inch  or  more,  and  still 
the  limb  possesses  free  motion  and 
strength.  This  shortening  causes  the 
neck  of  the  scapula  to  fall  forwards, 
and  makes  the  base  of  it  project  back- 
wards, giving  the  person  the  appear- 
ance of  having  the  chest  contracted  in 
front,  by  which  the  extent  of  range  of 
action  in  the  upper  extremity  will  be 
diminished,  although  sufficient  motion 
remains  for  the  ordinary  uses  of  the 
upper  extremity.     Where  the  fracture 

occurs  in  females,  in  whose  dress  the  clavicle  is  exposed  to  view,  it 
becomes  an  additional  object  to  get  the  bone  to  unite  as  evenly  as 
possible,  to  guard  against  the  formation  of  an  unsightly  lump  that 
will  remain  forever  afterwards.  The  more  the  deformity  is  prevented 
in  these  cases,  the  more  credit  the  surgeon  will  get  for  the  cure."^ 

M.  Mayor,  of  Lausanne,  thinks  that  up  to  this  day  no  successful 
mode  of  treatment  has  been  devised.  "Here  everything  appears  as 
yet  so  little  determined  that  each  day  sees  some  new  propositions  and 
different  procedures,"  etc.  He  believes,  however,  that  in  his  simple 
handkerchief  bandage,  with  straps  across  each  shoulder,  the  indications 
are  most  fully  accomplished  and  the  most  successful  results  are  obtain- 
ed. If,  however,  it  were  to  be  treated  without  apparatus,  the  horizon- 
tal position,  lying  upon  the  back,  would,  in  the  end,  make  the  most 
perfect  unions.^ 

Says  M.  Malgaigne :  "  The  prognosis,  considering  the  trivial  cha- 
racter of  this  fracture,  is  sufficiently  difficult.  For,  little  as  may  be 
the  displacement,  the  surgeon  ought  not  to  promise  a  reunion  without 
deformity ;  and  certain  successful  results,  proclaimed  from  time  to 
time,  betray,  on  the  part  of  those  who  relate  them,  the  most  extrava- 
gant exaggerations."^ 

'  Treatment  of  Fractures,  by  Joseph.  Amesbury,  vol.  ii.  p.  527.     London  ed.,  1831. 

*  Practical  Treatise  on  Fractures,  by  Edward  F.  Lonsdale,  pp.  207  and  209.  Lon- 
don ed.,  1838. 

'^  Nouveau  Systeme  de  Deligation  Chirurgicale,  par  Mathias  Mayor,  de  Lausanne,  p. 
384,  etc. :   (also  Atlas,  plate  3,  fig.  23.)     Paris  ed.,  1838. 

••  Traite  des  Fractures  et  des  Luxations,  par  J.  F.  Malgaigne,  tome  premier,  p.  473, 
Paris  ed.,  1847. 
IS 


194  FEACTUEES    OF    THE    CLAVICLE. 

M.  Nekton  having  spoken  of  the  various  plans  which  have  been 
suggested  to  retain  this  bone  in  place,  and  of  their  inefficiency,  comes 
at  last  to  speak  of  the  handkerchief  bandage  of  M.  Mayor,  and  re- 
marks : — 

"This  apparel  is  very  simple;  but  neither  will  it  remedy  the  over- 
lapping." *  *  *  *  "  Of  all  the  apparels  which  we  have  passed 
in  review  there  is,  then,  not  one  which  fills  completely  the  three  indi- 
cations usually  present  in  the  fracture  of  a  clavicle.  None  of  them 
oppose  the  displacement ;  they  have  no  effect,  with  whatever  care 
they  may  be  applied,  but  to  maintain  immobility  in  the  limb.  We 
think,  then,  that  it  is  useless  to  fatigue  the  patient  with  an  apparatus 
annoying,  and,  perhaps,  even  painful;  a  simple  sling,  secured  upon 
the  sound  shoulder,  will  be  sufficiently  severe.  Nevertheless,  as  this 
does  not  assure  so  complete  immobility  as  the  bandage  of  M.  Mayor, 
it  is  to  this  that  we  think  the  preference  ought  to  be  given  in  all  cases 
of  fractures  of  the  clavicle,  whether  accompanied  with  displacement  or 
not,  whether  they  occupy  the  middle  or  the  external  part  of  the  cla- 
vicle. If  the  fracture  presents  no  displacement,  we  shall  obtain  a  cure 
which  will  leave  nothing  to  be  desired.  If  there  is  a  tendency  to 
displacement,  the  consolidation  will  be  effected  with  a  deformity  more 
or  less  marked;  but  since  this  deformity  is  inevitable,  at  least  with 
adults,  whatever  may  be  the  apparel  which  we  employ,  it  is  evident 
that  the  apparatus  which  causes  the  least  constraint  ought  to  have  the 
preference.  We  may  remark,  farther,  that  this  union  with  deformity  in 
nowise  impairs  the  free  exercise  of  all  the  movements  of  the  member."^ 

"  The  venerable  gentleman  who  stands  at  the  head  of  American 
surgery,  and  whose  manipulations  with  the  roller  approach  very 
nearly  to  the  limits  of  perfection,  informed  us,  in  1824,  that  he  had 
never  seen  a  case  of  fractured  clavicle  cured  by  any  apparatus,  with- 
out obvious  deformity."^ 

I  need  not  say  that  the  "  venerable  gentleman"  to  whom  Dr.  Coates 
refers  in  this  passage,  was  the  late  Dr.  Physick,  of  Philadelphia. 

Treatment. — If  evidence  were  needed  beyond  that  which  has  been 
furnished,  of  the  difficulty  of  bringing  to  a  successful  issue  the  treat- 
ment of  this  fracture,  it  might  be  supplied,  one  would  think,  by  a 
reference  merely  to  the  immense  number  of  contrivances  which  have 
been  at  one  time  and  another  recommended. 

A  catalogue  of  the  names  only  of  the  men  who  have,  upon  this 
single  point,  exercised  their  ingenuity,  would  be  formidable,  nor  would 
it  present  any  mean  array  of  talent  and  of  practical  skill. 

All  these  surgeons,  however,  have  admitted  the  same  indications  of 
treatment  viz.,  that  in  order  to  a  complete  restoration  of  the  outer 
fragment,  which  alone  is  supposed  to  be  much  displaced,  we  are  to 
carry  the  shoulder  upwards,  outwards,  and  backwards.  But  as  to 
the  means  by  which  these  indications  can  be  most  easily,  if  at  all,  ac- 

'  Elemens  de  Pathologie  Chirurgicale,  par  A.  Nelaton,  tome  premier,  p.  720,  Paris 
ed.,  1844. 

■'■  Reynal  Coates,  Amer.  Med.  Journ.,  voL  xviii.  p.  62,  old  series.  It  is  probable  that 
Dr.  Physick  here  referred  to  complete  and  oblique  fractures  of  the  middle  third,  or  that 
Dr.  Coates  has  forgotten  the  precise  language  employed  on  this  occasion. 


FRACTUEES    OF    THE    CLAVICLE.  195 

complished,  the  widest  differences  of  opinion  have  prevailed  ;  and,  in 
the  debate,  it  may  be  seen  that,  while  on  the  one  hand,  no  invention 
has  wanted  for  both  advocates  and  admirers,  on  the  other  hand,  no 
method  has  escaped  its  equivalent  of  censure. 

Hippocrates,  Celsus,  Dupuytren,  Flaubert,  Lizars,  Pelletan,  and 
others,  directed  the  patients  to  lie  upon  their  backs,  with  little  or  no 
apparatus,  but  generally  with  the  spinal  column  so  supported  and 
lifted  with  pillows,  as  that  the  shoulders  would  by  their  own  weight 
fall  backwards.  S.  Cooper  and  Dorsey  also  recommend  that  the 
patients  should  be  confined  in  this  position  during  most  of  the  treat- 
ment; and,  from  the  account  given  by  Dr.  Lente,  it  may  be  inferred 
that  a  similar  plan  is  generally  adopted  in  the  New  York  City  Hos- 
pital. "  But  this  result  (deformity)  rarely  happens  when  the  patient 
has  strictly  followed  the  directions  of  the  surgeon,  as  to  position  espe- 
cially, for  it  is  by  position  more  than  by  any  other  remedial  means, 
that  a  good  result  is  to  be  effected.  *****  The  persevering 
continuance  of  the  supine  position  in  bed,  with  the  head  low,  and,  if 
necessary,  a  pad  between  the  shoulders.  This  is  the  treatment  uni- 
formly adopted  by  Dr.  Buck,  in  the  hospital,  and  the  results  of  his 
treatment  are  certainly  such  as  to  recommend  it  highly." 

Nearly  the  same  method  we  find  recommended  by  Alfred  Post,  in 
1840,  then  one  of  the  surgeons  of  that  hospital ;  the  arm  being  merely 
kept  in  a  sling  and  bound  to  the  side,  with  the  patient  lying  upon  his 
back ;  and  Dr.  Post  mentions  a  case  treated  in  this  manner,  which 
terminated  with  very  little  deformity.' 

Dr.  Eve,  of  Nashville,  Tenn.,  and  Dr.  Eastman,  of  Broome  County, 
N.  Y.,  have  also  employed  this  method  successfully;^  while  Malgaigne 
declares  it  to  be  the  most  reliable  means  of  obtaining  an  exact  union. 

Albucasis,  Lanfranc,  Guy  de  Chauliac,  Petit,  Parr,  Syme,  Skey, 
Brunninghausen,  Parker,^  and  very  many  others,  especially  among  the 
English,  iiave  preferred,  in  order  to  carry  the  shoulders  back,  a  figure- 
of-8,  while  Desault,  Colles,  South,  and  Samuel  Cooper,  have  repre- 
sented this  bandage  as  useless,  annoying,  and  mischievous. 

Heister,  Chelius,  Miller,  Breffield,  Keckerly,*  Coleman,*  Welch,^ 
Hunton,'  prefer,  for  this  purpose,  some  form  of  back-splint,  extending 
from  acromion  to  acromion,  against  which  the  shoulders  may  be  pro- 
perly secured.  Parker  says  that  splints  of  this  kind,  with  a  figure-of- 
8  bandage,  are  "  better  than  all  the  apparatus  ever  invented."  While 
Mr.  South  gives  his  testimony  in  relation  to  all  dressings  of  this  sort, 
as  follows :  "  I  do  not  like  any  of  the  apparatus  in  which  the  shoulders ' 
are  drawn  back  by  bandages,  as  these  invariably  annoy  the  patient, 

'  N.  Y.  Journ.  of  Med.,  vol.  ii.  p.  266. 

^  Boston  Med.  and  Surg.  Journ.,  vol.  Ivi.  p.  468. 

^  Parker,  Samuel  Cooper's  First  Lines,  Amer.  ed.,  vol.  ii.  p.  325. 

*  Keckeriy,  Amer.  Journ.  of  Med.  Sci.,  vol.  xv.  p.  115  ;  also,  my  Report  on  Deformi- 
ties after  Fractiires,  in  Trans,  of  Amer.  Med.  Assoc,  vol.  viii.  p.  440. 

*  Coleman,  New  York  Journ.  of  Med.,  second  series,  vol.  iii.  p.  274,  from  New  Jersey 
Med.  Rep. 

^  Welch,  Trans,  of  Amer.  Med.  Assoc,  vol.  viii.;  my  Report  on  Deformities  after 
Fractures,  appendix,  p.  441. 

'  Hunton,  ibid.;  also,  New  Jersey  Med.  Rep.,  vol.  v.  p.  146. 


196 


FRACTUEES    OF    THE    CLAVICLE. 


often  cause  excoriation,  and  are  never  kept  long  in  place,  the  person 
continually  wriggling  them  off  to  relieve  himself  of  the  pressure." 

Fox,'  Brown,^  Desault,  and  others  bring  the  elbow  a  little  forwards, 
and  then  lift  the  shoulder  upwards  and  backwards.      Wattman  and 

Fig.  42. 


m     a. 


d       U 


E.  C.  Keckerlt's  Appakatus. — "The  upper  figure  exhibits  a  front  view,  and  the  lower  a  back  view  of 
the  splint,  a,  a.  Are  two  bandages  with  buckles  attached  to  one  end  of  each.  66,  66.  Are  four  mortised 
holes  for  the  passage  of  the  two  bandages,  a,  a.  c.  A  portion  of  the  splint  padded,  to  prevent  its  bruising 
the  patient,  d,  d.  Two  loops  of  leather,  tacked  on  the  back  of  the  splint,  for  the  passage  of  the  bandages, 
where  the  mortised  holes  are  too  far  apart  for  the  breadth  of  the  patient  from  shoulder  to  shoulder. 

"  Mode  of  Application. — The  end  of  the  splint  corresponding  to  the  uninjured  side  is  to  be  pressed  close 
to  the  back  of  the  shoulder,  and  retained  so  by  drawing  the  bandage  tight,  and  retaining  it  by  means  of 
the  buckle.  Previous  to  fixing  the  bandage,  it  should  be  passed  through  two  loops  on  a  small  pad,  which 
is  to  be  placed  in  the  axilla.  This  pad  is  used  for  the  purpose  of  preventing  the  cutting  of  the  bandage. 
After  passing  the  other  bandage  through  two  loops,  on  a  large,  cuneiform  pad,  which  is  placed  in  the 
axilla  of  the  injured  side,  it  is  drawn  sufficiently  tight  and  secured  by  the  buckle.  The  last  thing  to  be 
done  is  'to  place  a  handkerchief,  doubled  into  a  triangular  form,  in  such  a  manner  over  the  arm,  the 
front  and  back  parts  of  the  thorax,  as  that  it  shall  draw  and  confine  the  arm  of  the  injured  side  close  to 
the  body,  give  it  support,  and  prevent  its  falling  down." 


Fig.  43. 


Fig.  44. 


Hunton's  "  yoke  splint,"  modified  by  Day. 


Front  view  of  Welch's  apparatus. 


'  Fox,  Liston's  Practical  Surgery,  Amer.  ed.,  p.  47. 
^  Brown,  Sargent's  Minor  Surgery,  p.  132. 


FRACTUEES    OF    THE    CLAVICLE. 
Fig.  45. 


197 


Back  View  of  Welch's  Apparatus. — A.  "Vertical  or  dorsal  piece,  b,  b.  Lateral  or  thoracic  arms,  c,  c. 
Oblique  or  cervical  arms,     d,  d.  Transverse  or  acromial  arms,    e,  e.  Leather  shoulder-caps  and  straps. 

The  frame,  consisting  of  the  dorsal  piece  with  the  thoracic  and  cervical  arms,  is  formed  of  flexible 
metal,  which  yields  sutiiciently  to  adapt  it  always  to  the  motions  of  the  spine  and  chest.  The  lateral 
or  thoracic  arms  encircle  the  body,  and  the  vertical  or  cervical  arms,  passing  upwards,  outwards,  and 
forwards,  conform  to  the  sides  of  the  neck.     The  whole  are  well  and  thickly  padded. 

The  transverse  or  acromial  arms,  running  parallel  with  the  spine  of  the  scapula  to  the  acromion  pro- 
cess, are  made  of  elastic  steel,  slightly  curved  backwards  at  their  outer  extremities,  so  that,  when  the 
shoulders  are  made  fast  to  them  by  the  shoulder-straps,  they  will  tend  constantly  to  pull  the  shoulders 
outwards  and  backwards. 

The  several  parts  of  the  apparatus  are  adjusted  to  persons  of  different  sizes. 

1st.  The  cervical  arms  can  be  made  to  approach  or  to  separate  from  the  arch,  and  they  can  also  be 
made  longer  or  shorter. 

2d.  The  acromial  arms  can  be  lengthened  or  shortened  upon  either  side,  and  when  in  use  the  arm 
opposite  the  broken  bone  should  be  longer  than  the  one  opposite  the  sound  bone,  to  give  greater  freedom 
to  the  arm  upon  this  side. 

In  the  front  view  of  the  apparatus  is  seen  "  a  padded  metallic  ring,  the  upper  edge  of  which  is  placed 
nearly  as  high  as  the  upper  edge  of  the  sternum.  Above  are  straps  connecting  it  with  the  cervical  arms. 
Laterally  is  a  strap  connecting  with  the  shoulder-cap  of  the  sound  side,  to  prevent  the  central  ring  from 
inclining  toward  the  injured  side  ;  opposite  this  is  another  strap  attached  also  to  the  sling  supporting  the 
arm  and  drawing  the  arm  of  the  injured  side  inwards;"  below  these  are  straps  connecting  with  the 
thoracic  arms,  and  at  the  inferior  point  of  the  ring  is  a  strap  designed  to  support  the  hand  and  forearm. 

"The  sling  in  which  the  arm  rests  has  thin  strips  of  metal  sewed  into  the  cloth,  at  the  sides  of  the 
arm  both  above  and  below  the  elbow,  with  rings  for  the  straps,  in  order  to  give  a  uniform  and  unyielding 
support  to  the  arm  the  entire  length  of  the  sling." 

The  axillary  pad  may  be  made  in  the  usual  form,  and  secured  in  the  ordinary  mode. 

Lonsdale  carry  the  elbow  still  further  forwards,  so  as  to  lay  the  hand 
across  the  opposite  shoulder,  while  Guillou  carries  the  hand  and  fore- 
arm behind  the  patient,  and  then  proceeds  to  lift  the  shoulder  to  its 
place. 

ThusDesault,  Fox,  and  Wattman  accomplish  the  indication  to  carry 
the  shoulder  back,  by  lifting  the  humerus  while  the  elbow  is  in  fi-ont 
of  the  body,  and  Guillou  accomplishes  the  same  indication  by  lifting 
the  humerus  when  the  elbow  is  a  little  behind  the  body.  Chelius  also 
says :  "The  elbow,  as  far  as  possible,  is  to  be  laid  backwards  on  the 
body." 


198 


FEACTUEES    OF    THE    CLAVICLE. 


Figure-of-8. 


Sargent,  who  believes  that  with  Fox's  apparatus  "  the  occurrence  of 
deformity  is  the  exception,"  and  not  the  rule,  and  prefers  it  to  all 

others,  has  treated  three  cases  by  Guil- 
lou's  method,  and  is  perfectly  satisfied 
with  its  operation. 

Hollingsworth,  of  Philadelphia,  has 
also  treated  one  case  successfully  by 
Guillou's  method,  and  adds  his  testi- 
mony in  its  favor.  But  how  shall  we 
explain  these  equal  results  from  oppo- 
site modes  of  treatment  ?  Is  the  indica- 
tion to  carry  the  shoulders  back,  which 
Fox  sought  to  accomplish  by  pressing 
the  elbow  upwards  and  backwards,  as 
easily  attained  by  pressing  the  elbow 
upwards  and  forwards  ?  Or  are  we 
not  compelled  to  infer  that  there  has 
been  some  mistake  as  to  the  precise 
amount  of  good  accomplished  by  the 
apparatus  in  either  case?  Moreover, 
Coates,^  Keal,  and  others,  instruct  us 
that  the  only  safe  and  proper  position  for  the  humerus  is  in  a  line 
with  the  side  of  the  body,  and  that  it  must  neither  be  carried  forwards 
nor  backwards. 

Paulus  iEgineta,  Boyer,  Desault,  Pecceti,  Liston,  Fergusson,  Samuel 
Cooper,  Erichsen,  Miller,  Skey,  Dorsey,^  Gibson,^  Fox,  H.  H.  Smith,'* 
Norris,^  Sargent,  Eastman,"  recommend  an  axillary  pad,  while  Riche- 
rand,  Velpeau,  Dupuytren,  Benjamin  Bell,  Syme,  deny  its  utility,  or 
affirm  its  danger.  Dr.  Parker  has  seen  one  patient  in  whom  paralysis 
of  the  arm  resulted  from  the  pressure  upon  the  brachial  nerves,  in  the 
attempt  "  to  ]3ry  the  shoulder  out ;"  and  I  have  myself  recorded 
another. 

Cabot,  of  Boston,  Massachusetts,  has  recommended  a  mould  of  gutta 
percha  laid  over  the  front  and  top  of  the  chest.''' 

Desault's  plan,  which  took  its  origin,  as  Velpeau  thinks,  in  the 
spica  of  Glaucius,  under  various  modifications,  is  recommended  by 
Delpech,  Cruveilhier,  Lasere,  Flamant,  Samuel  Cooper,  Fergusson, 
Liston,  Cutler,  Physick,  Dorsey,  Coates,  and  Gibson ;  while  by  Vel- 
peau, Syme,  Colles,  Chelius,  Samuel  Cooper,  and  Parker,  it  is  regarded 
as  inefficient  and  troublesome.  Says  Mr.  Cooper :  "In  this  country, 
many  surgeons  prefer  Desault's  bandages;  but  I  do  not  regard  them 
as  meeting  the  indications,  and  consider  them  worse  than  useless." 


'  Coates,  Amer.  Journ.  Med.  Sci.,  vol.  xviii.  p.  62. 

^  Dorsey,  Elements  of  Surgery,  vol.  i.  p.  133. 

^  Gibson,  Institutes  and  Practice  of  Surgery,  vol.  i.  p.  271. 

*  H.  H.  Smith,  Practice  of  Surgery,  p.  354. 

^  Norris,  Liston's  Practical  Surg.,  Amer.  ed.,  p.  46. 

^  Eastman,  Apparatus  for  Fractured  Clavicle,  by  Paul  Eastman,  of  Aurora,  111.;  Bos- 
ton Med.  and  Surg.  Journ.,  vol.  xxiii.  p.  179. 

^  Cabot,  Eost.  Med.  and  Surg.  Journ.,  vol.  lii.  p.  232. 


FEACTURES    OF    THE    CLAVICLE. 


199 


Fig.  47. 


The  dextrine  bandages,  or  apparatus  immobile^  of  Blandin,  Yelpeaii, 
and  others,  constitute  only  another  form  of  the  bandage  dressing  of 
Desault.  In  this  connection  it  ought  to  be  noticed  that  Velpeau  does 
not  regard  the  employment  of  this  apparatus,  or  of  any  other  demanding 
great  restraint,  as  imperative.  In  his  great  work  on  anatomy,  re- 
ferring to  the  fact  that  when  the  bone  is  broken  and  overlapped,  the 
patient  is  still  able,  in  many  cases,  to  move  the  arm  freely,  he  re- 
marks: "Do  not  these  cases  give  support  to  the  opinion  of  those  who 
admit  that  fractures  of  the  clavicle  do  not  actually  require  any  other 
apparatus  than  the  simple  supporting  bandage?"  "It  is  necessary  to 
observe,"  he  adds,  "  that  by  thus  acting  we  do  not  prevent  an  over- 
lapping,"^ etc. 

The  sling,  in  some  of  its  forms,  is  employed  by  Richerand,  Huber 
thai,  Colles,  Miller,  Fox,  Stephen  Smith,^  H.  H.  Smith,  Bartlett,^  Levis," 
Dugas,*  Benjamin  Bell,  Bransby  Cooper, 
Earle,  Chapman,  Keal,  and  by  a  large 
majority  of  the  English  surgeons ;  while 
Dr.  Gibson  declares  the  sling  bandage 
employed  so  much  by  the  English,  "the 
most  inefficient,  contemptible,  and  in- 
jurious of  all  contrivances  for  such  pur- 
poses." 

No  apparatus,  perhaps,  has  been  so 
generally  employed,  among  American 
surgeons,  as  that  form  of  the  sling  in- 
troduced by  Dr.  George  Fox  into  the 
Pennsylvania  Hospital  in  1828;  since 
which  time  no  other  has  ever  been  used 
in  that  institution  for  the  treatment  of 
broken  clavicles. 

Sargent  says  of  it :  "  Fractures  of  the 
clavicles,  treated  by  this  apparatus,  are 
daily  dismissed  from  the  Pennsylvania 
Hospital,  and  by  surgeons  in  private 
practice,  cured  without  perceptible  de- 
formity." 

Norris,  in  a  note  to  Liston^s  Practical 
Surgery^  affirms  that  "  the  chief  indica- 
tions in  the  treatment  of  fracture  of  the 
clavicle  are  perfectly  fulfilled  by  the  use 
of  this  apparatus." 

Smith,  in  his  Minor  Surgery^  declares  that  Fox's  apparatus  accom- 
plishes "perfect  cures"  in  very  many  cases,  and  that  it  is  "a  very  rare 
thing  for  a  simple  case  to  go  out  of  the  house  (Pennsylvania  Hospital) 


E.  Bartlett's  Apparatps. — "For  an 
axillary  pad,  roll  a  strip  of  Tfoollen  flannel, 
four  or  five  inches  wide,  around  the  axillary 
strap,  to  the  size  required.  The  apparatus 
may  be  used  for  either  side  by  changing 
the  attachment  of  the  sling."     (Bartlett.) 


'  Velpeau,  Anatomy,  Amer.  ed.,  vol.  i.  p.  242. 

2  Stephen  Smith,  New  York  Journ.  Med.,  vol.  ii.  3d  series,  p.  384  (May,  1^-57). 

3  Bartlett,  My  "Report   on  Defor."   etc.,  Appendix;   also  Bost.  Med.   and   Surg. 
Journ.,  vol.  li.  p.  404. 

''  Levis,  H.  H.  Smith's  Practice  of  Surg.,  p.  365. 
^  Dugas,  Report  on  Surgery. 


200 


FEACTUEES    OF    THE    CLAVICLE. 


with  any  other  dsformity  save  that  which  time  cures,  viz.  the  depo- 
sition of  the  provisional  callus."  He  has  also  repeated  substantially 
the  same  opinion  in  his  larger  work  entitled  Practice  of  Surgery. 

Such  testimony  in  favor  of  any  dressing  demands  respectful  atten- 
tion ;  and  I  shall  not  be  regarded  as  detracting  from  the  respect  due  to 
these  authorities,  when  I  express  my  belief  that  it  is  in  deference  to  the 
distinguished  reputation  of  the  surgeons  who  have  during  the  last 
thirty  years  had  charge  of  the  services  in  that  hospital,  and  who  have 
been  so  loud  in  its  praise,  that  the  use  of  this  apparatus  has,  with  us, 
become  so  general.  I  believe,  also,  that,  in  some  measure,  this  general 
preference  is  due  fairly  to  the  intrinsic  excellence  of  the  dressing. 
But  I  must  be  permitted  to  express  a  doubt  whether  it  has  made  de- 
formities of  the  clavicle  "the  exception,  instead  of  the  rule,"  with  us. 
I  have  used  this  dressing  oftener  than  any  other  form,  and  yet  my  suc- 
cess has  by  no  means  been  so  flattering 
as  has  been  the  success  of  these  gentle- 
men, I  have  seen  others  employ  it,  also, 
and  with  pretty  much  the  same  results. 
Nor  ought  it  to  be  forgotten  that,  in 
Great  Britain,  by  far  the  greater  majo- 
rity of  surgeons  employ  an  apparatus 
essentially  the  same.  I  have  seen  it 
in  many  of  the  hospitals,  and  Mr.  Bick- 
ersteth,  one  of  the  surgeons  of  the  Liver- 
pool Infirmary,  informed  me,  in  1844, 
that  it  had  been  in  use  with  them  as 
long  as  thirty  years.  All  that  has  justly 
been  said  against  the  English  mode  of 
dressing  by  slings,  is  equally  true  of  this; 
and  whatever  has  been  affirmed  of  the 
danger  of  using  an  axillary  pad  applies 
as  much  to  this  as  to  any  other  mode  of 
using  the  same. 

I  believe,  however,  that  in  the  Penn- 
sylvania Hospital,  the  axillary  pad  em- 
ployed is  not  so  large,  and  especially, 
not  so  thick,  as  that  recommended  by 
Desault,  and  in  this  respect  it  is  plainly 
an  improvement;  but  then,  in  the  same 
proportion  that  it  is  made  less  thick,  it  is 
less  powerful  to  accomplish  the  indica- 
tion in  question ;  and  if  it  merely  fills 
the  axillary  space,  then  it  is  no  longer  a 
fulcrum  upon  which  the  arm  is  to  ope- 
rate as  a  lever,  but  it  is  only,  in  its  effect, 
"  retentive." 

Eegarding,  then,  the  importance  of  this  question  to  the  interests  of 
surgery,  and  observing  the  wide  differences  of  opinion  which  are  en- 
tertained here  and  elsewhere  as  to  the  real  value  of  this  dressing,  is  it 
asking  too  much  of  these  gentlemen  that  they  will  present  us  some 


George  Fox's  Apparatus  "consists  of  a 
firmly  stuffed  pad  of  a  wedge  shape,  and 
about  half  as  long  as  the  humerus,  hav- 
ing a  band  attached  to  each  extremity  of 
its  upper  or  thickest  margin  ;  a  sling  to 
suspend  the  elbow  and  forearm,  made  of 
strong  muslin,  with  a  cord  attached  to 
the  humeral  extremity,  and  another  to 
each  end  of  the  carpal  portion  ;  and  a 
ring  made  of  muslin  stuffed  with  cotton 
to  encircle  the  sound  shoulder,  and  serve 
as  means  of  acting  upon  and  receiving 
the  sling."  {Sargent.) 


FKACTURES    OF    THE    CLAVICLE.  201 

more  precise  statistical  testimony?  It  will  be  observed  that  its  advo- 
cates claim  for  it  what  is  not  to-day,  at  least,  claimed  for  any  other 
apparatus,  viz :  that,  under  its  use  in  the  Pennsylvania  Hospital,  and 
in  the  hands  of  private  practitioners,  so  far  as  they  have  seen,  deform- 
ities have  become  the  "exception."  It  is  affirmed  to  answer  "per- 
fectly" all  the  indications.  By  which  it  must  be  intended  to  say,  that, 
in  addition  to  both  of  the  other  indications,  that  also,  which  has  always 
heretofore  been  found  so  difficult,  if  not  impossible,  the  carrying  out 
of  the  shoulder,  is  in  a  majority  of  cases  perfectly  accomplished — the 
clavicles  are  not  shortened. 

If  it  is  intended,  however,  to  say  that  a  shortening  is  not  generally 
prevented,  but  only  that  no  unseemly  projection  of  the  fractured  ends 
will  be  found  to  result,  I  reply,  that  then  it  does  not  ansvi^er  all  the 
indications;  and  I  beg,  further,  to  suggest  that  the  avoidance  of  an 
upward  projection  seems,  to  me,  to  depend  much  more  upon  that 
part  of  any  apparatus  which  lifts  the  shoulder,  and  which  belongs  to 
a  multitude  of  other  forms  of  dressing  as  well  as  to  that  in  question, 
than  upon  that  which  forces  the  shoulder  out,  and  it  may  be  accom- 
plished, in  a  majority  of  cases,  as  well  without  an  axillary  pad,  with 
a  mere  sling,  as  with  it.  But,  in  fact,  my  experience  has  convinced 
me  that  the  absence  or  presence  of  such  a  projection,  after  union,  is 
due  much  to  the  circumstances  of  the  fracture,  as  to  whether  it  is 
more  or  less  oblique ;  and  still  more  especially,  to  the  degree  of  round- 
ness, or  emaciation  of  the  patient,  rather  than  to  any  form,  or  part,  or 
condition  of  the  apparatus.  It  will  be  found  more  distinct  in  oblique 
fractures  than  in  transverse,  and  much  more  marked  in  thin  persons 
than  in  plump,  or  fat  persons,  and  more  so  in  muscular  than  in  non- 
muscular.  In  short,  I  affirm  that  such  a  projection  has  occurred  as 
often  under  my  observation,  when  this  dressing  has  been  used,  as  it 
has  when  other  forms  have  been  employed. 

Finally,  while  I  deprecate  incautious  assumptions  in  regard  to  the 
capabilities  of  any  form  of  dressing  for  broken  collar  bones,  a  disposi- 
tion to  which  is  manifested  by  more  than  one  advocate  of  special 
plans,  I  am  ready  to  bear  my  humble  testimony  in  favor  of  that  one 
of  whose  claims  t  have  taken  the  liberty  to  speak  so  freely,  and  which 
is  usually  known  in  this  country  by  the  name  of  Fox's  apparatus, 
consisting  essentially  of  a  sling,  axillary  pad,  and  bandages  to  secure 
the  arm  to  the  chest,  and  to  which  the  stuffed  collar  is  a  convenient 
accessory,  but  admits  of  various  modifications,  answering  the  same 
ends.  Among  the  considerable  variety  of  dressings  which  I  have 
used,  this,  either  with  or  without  such  slight  modifications  as  I  shall 
presently  suggest,  has  seemed  to  be  most  simple  in  its  construction, 
the  most  comfortable  to  the  patient,  the  least  liable  to  derangement 
(if  I  except  Yelpeau's  dextrine  bandage),  and  as  capable  as  any  other 
of  answering  the  several  indications  proposed. 

No  apparatus  is  better  able  to  answer  the  first  indication,  namely, 
"  to  carry  the  shoulder  up,"  and  thus  to  bring  the  fragments  into  line. 
If,  as  not  un frequently  happens,  the  outer  end  of  the  inner  fragment 
is  also  carried  a  little  upwards  and  forwards,  it  may  be,  in  some 
measure,  replaced  by  inclining  the  head  to  the  injured  side,  or  by  a 


202  FRACTUEES    OF    THE    CLAVICLE. 

carefully  adjusted  compress  and  bandage.  But  it  is  not  probable  that 
any  patient  will  consent  to  remain  a  long  time  in  a  position  so  un- 
natural and  constrained;  nor  is  it  very  easy,  as  the  experiment  will 
show,  to  maintain  a  steady  pressure  upon  this  portion  of  the  broken 
clavicle. 

The  second  indication,  "to  carry  the  shoulder  back,"  is  certainly 
much  more  difficult  of  accomplishment  than  the  first;  and  it  does  not 
seem  to  me  to  be  fully  met  by  the  sling  dressing,  but,  until  some  mode 
is  devised  less  objectionable  than  any  I  have  yet  employed,  or  than 
any,  the  mechanism  of  which  I  have  seen  described,  I  see  no  alterna- 
tive but  to  trust  to  that  action  of  the  muscles  attached  to  the  scapula, 
by  which,  as  Desault  first  explained,  when  the  shoulder  is  lifted  per- 
pendicularly, it  is  also  in  some  degree  carried  backwards,  and  that, 
too,  it  has  occurred  to  me  frequently  to  observe,  just  as  much  as  when 
the  upward  pressure  is  made  with  the  elbow  placed  in  front  of  the 
body. 

It  is  my  belief,  however,  from  the  evidences  now  before  us,  that  the 
third  indication,  "  to  carry  the  shoulder  out,"  still  remains  unaccom- 
plished :  that  it  cannot  be  claimed  for  this,  or  for  any  other  apparatus 
yet  invented,  that,  in  a  certain  class  of  cases  which  I  have  sufficiently 
indicated,  constituting  a  vast  majority  of  the  whole  number,  it  is  able 
to  prevent  a  riding  of  the  fragments.  Nor,  seeing  the  difficulties  in 
the  way,  and  the  amount  of  talent  which  has  been  already  devoted  to 
their  removal,  have  I  much  confidence  that  this  end,  so  desirable,  and 
so  diligently  sought,  will  ever  be  attained.  Yet  it  is  presumptuous, 
perhaps,  to  say  what  the  skill  and  ingenuity  of  a  profession  whose 
labors  never  cease,  may  not  hereafter  accomplish. 

Having  already  expressed  my  preference  for  the  sling,  I  have  only 
to  add  what  I  consider  necessary  modifications  in  the  form  of  this 
dressing  recommended  by  Dr.  Fox. 

Dr.  Coates,  in  the  excellent  })aper  already  referred  to,^  calls  attention 
to  the  danger  of  making  too  much  pressure  upon  the  brachial  artery 
and  nerves,  when  the  axillary  pad  is  used,  and  the  arm  is,  at  the  same 
time,  carried  forwards  upon  the  body.  In  bringing  the  elbow  for- 
wards so  as  to  lay  the  forearm  across  the  body,  the  humerus  is  made 
to  rotate  inwards,  and  the  brachial  artery  and  nerves  are  brought  into 
more  direct  apposition  with  the  pad.  The  same  objection  must  hold, 
only  in  a  greater  degree,  to  M.  Guillou's  method  of  carrying  the  fore- 
arm across  the  back. 

The  humerus  ought  then  to  be  permitted  to  hang  perpendicularly 
beside  the  body,  and  thus  the  nerves  and  bloodvessels  will  be  removed 
in  a  great  measure,  yet  not  entirely,  from  pressure.  The  pad  (to 
be  employed  only  as  a  part  of  the  retentive  means,  and  not  as  a  ful- 
crum) should  be  no  thicker  than  is  necessary  to  fill  completely  the 
axillary  space  when  the  elbow  is  made  to  press  snugly  against  the  side 
of  the  body. 

In  consequence  of  having  placed  the  elbow  farther  back  than  is 
recommended  by  Dr.  Fox,  it  will  be  necessary,  also,  to  vary  in  some 

'  Am.  Journ.  Med.  Sci.,  vol.  xviii.  p.  62. 


FEACTURES    OF    THE    CLAVICLE. 


203 


The  Author's  Apparatus. 


way,  the  suspensory  tapes ;  those  coming  from  the  humeral  portion 
of  the  arm-tray  must  pass  in  equal  numbers,  and  in  opposite  directions 
— before  and  behind  the  body  —  toward 
the  stuffed  collar ;  and  each  set  of  front 
and  back  tapes,  attached  to  the  humeral 
portion  of  the  tray,  must  be  in  pairs,  for 
the  convenience  of  tying.  I  find  it  neces- 
sary also  to  secure  the  arm  to  the  body  by 
two  or  three  turns  of  a  roller,  applied 
always  lightly  and  with  great  care,  so  that 
its  pressure  shall  be  in  no  degree  painful 
or  uncomfortable. 

An  experience,  limited  to  the  two  follow- 
ing examples,  induces  me  to  think  that 
very  many  cases  would  be  brought  to  a  con- 
clusion equally  satisfactory  without  any  form 
of  apparatus,  by  retaining  the  patient  a  few 
weeks  in  the  recumbent  posture  upon  the 
back,  as  recommended  by  Hippocrates  and 
others ;  and  to  which  plan  allusion  has  al- 
ready been  made. 

Jan.  2,  1856— Mary  Ann  S.,  £et.  24,  fell 
down  a  flight  of  stairs,  breaking  the  right 
collar  bone  obliquely  near  its  middle.  She 
was  unwilling  to  submit  to  bandages,  and  I  directed  her  simply  to  lie 
upon  her  back  in  bed.  On  the  fourteenth  day  the  fragments  had  united; 
and  at  the  end  of  the  third  week  I  dismissed  her  with  an  overlapping 
of  the  fragments  of  less  than  half  an  inch,  and  with  scarcely  any  percep- 
tible deformity. 

Alexander  Mooney,  set.  33,  was  admitted  to  the  Buffalo  Hospital, 
December  3,  1856,  with  an  oblique  fracture  of  the  left  clavicle,  at  the 
outer  end  of  the  middle  third.  On  measurement  we  found  the  frag- 
ments overlapped  nearly  half  an  inch. 

In  presence  of  a  class  of  medical  students  I  applied  Bartlett's  appa- 
ratus, a  very  ingenious  and  convenient  form  of  the  sling  dressing,  and 
the  same  which  is  now  in  use  at  the  Mass.  General  Hospital,  in  Boston. 
On  the  following  day  the  apparatus  was  found  to  be  loose,  and  it  was 
carefully  retighteued.  On  the  third  and  fourth  day,  also,  it  was  found 
necessary  to  readjust  it  more  or  less,  and  the  fragments  of  the  broken 
clavicle  continued  to  overlap. 

On  the  fifth  day  Bartlett's  apparatus  was  removed,  and  the  patient 
laid  upon  his  back  in  bed,  with  his  arm  simply  tied  to  the  side  of  his 
body  by  a  few  turns  of  a  roller. 

On  the  tenth  day  all  motion  had  ceased  between  the  fragments ;  but 
he  was  kept  in  bed  three  weeks. 

Jan.  10,  1857,  he  was  discharged  from  the  hospital,  with  an  over- 
lapping of  only  about  one  quarter  of  an  inch,  and  with  scarcely  any 
perceptible  deformity. 

In  cases  of  partial  fracture  accompanied  with  a  persistent  bend  in 
the  line  of  the  axis  of  the  bone,  it  is  proper  to  make  some  attempt  by 


204  FEACTURES    OF    THE    SCAPULA. 

moderate  pressure  directly  upon  the  salient  fragments,  to  restore  them 
to  place ;  but  I  confess  that  I  have  never  jet  succeeded  in  accomplish- 
ing anything  in  this  way.  Nor  is  it  a  matter  of  much  consequence,  I 
imagine,  since,  as  I  have  already  explained  when  speaking  of  partial 
fractures  in  general,  the  line  of  the  axis  of  the  bone  will  eventually, 
at  least  in  a  majority  of  cases,  be  completely  restored. 

The  only  treatment  which  seems  then  to  be  indicated,  and  the  only 
treatment  which  I  have  of  late  adopted  in  these  cases,  is  to  place  the 
hand  and  forearm  of  the  child  in  a  sling,  or  I  direct  the  mother  to 
make  fast  the  sleeve  to  the  front  of  the  dress  in  such  a  way  that  the 
child  cannot  use  the  arm  until  the  union  is  consummated.  Even  this 
precaution  I  have  several  times  omitted  with  no  injury  to  the  patient. 

For  a  more  full  consideration  of  partial  fractures  of  the  clavicle,  I 
beg  to  refer  the  reader  to  the  chapter  on  "  Partial  Fractures,"  &c. 


CHAPTER    XIX. 

FRACTUEES  OF  THE  SCAPULA. 

Fractures  of  the  scapula  may  be  divided  into  those  which  occur 
through  the  body,  the  neck,  the  acromion,  and  coracoid  processes. 

§  1.  Fractures  op  the  Body  of  the  Scapula. 

Under  this  title  I  propose  to  consider  not  only  fractures  of  the 
"body"  properly  speaking,  but  also  fractures  of  the  angles  and  of  the 
spine. 

Causes. — It  is  usually  broken  by  the  fall  of  some  heavy  body  directly 
upon  the  bone,  or  by  some  severe  crushing  accident,  by  the  kick  of  a 
horse,  by  a  fall  upon  the  back — in  short,  by  direct  causes  alone,  and  by 
such  causes  as  operate  with  great  violence. 

Malgaigne  says  that  a  Doctor  Heylen  has  recently  published  a  case 
of  this  fracture  which  he  believes  to  have  been  the  result  of  muscular 
action,  occurring  in  a  man  forty-nine  years  old.  The  case,  however, 
is  not  stated  so  clearly  as  to  relieve  us  entirely  of  a  doubt  as  to  the 
nature  and  cause  of  the  accident. 

I  have  myself  had  occasion  to  treat  but  one  case,  and  that  was 
produced  by  a  fall  upon  the  back.  It  was  a  fracture  of  the  body 
below  the  spine.  Dr.  Neill  called  my  attention  to  a  fracture  involving 
the  spine  of  the  scapula  then  under  treatment  in  the  Pennsylvania 
Hospital,  in  the  year  1855.  I  do  not  now  remember  to  have  ever 
seen  another  example.  There  are  two  cabinet  specimens  of  fracture 
of  the  body  of  the  scapula  below  the  spine   in  the  Pennsylvania 


FKACTUEES    OF    THE    BODY    OF    THE    SCAPULA.  205 

Medical  College,  and  two  involving  the  spine.  Dr.  Mutter  has  in  his 
collection  a  fracture  of  the  posterior  angle,  and  Dr.  March  has  a  speci- 
men of  fracture  of  the  body.  I  believe  that  Dr.  Charles  Gibson,  of 
Eichraond,  has  also  one  or  two  specimens  of  this  fracture.  I  know  of 
no  other  museum  specimens  in  this  country  except  my  own  of  partial 
fracture,  described  in  the  chapter  on  Partial  Fractures. 

Ravaton,  after  a  practice  of  fifty  years,  declared  that  he  had  never 
seen  a  fracture  of  the  scapula,  except  as  it  had  been  produced  by  fire- 
arms. Among  2358  fractures  reported  from  Hotel  Dieu  during  a 
period  of  twelve  years,  only  four  examples  of  fracture  of  the  scapula 
are  recorded ;  and  at  Middlesex  Hospital,  Lonsdale  has  noticed  among 
1901  fractures,  only  eight  of  the  body  of  the  scapula. 

The  infrequency  of  this  fracture  is  no  doubt  due  in  a  great  measure 
to  the  elasticity  of  the  ribs,  to  the  mobility  of  the  scapula,  and  to  the 
softness  of  the  muscular  cushion  upon  which  it  reposes. 

Syviptoms. — Since  this  bone  is  seldom  broken  except  by  great  force 
directly  applied,  the  usual  signs  of  fracture  are  likely  to  be  concealed 
by  the  speedy  occurrence  of  swelling.  It  is  for  this  reason  that  it 
becomes  necessary  generally  that  the  examination  should  be  made 
with  great  care  before  we  can  safely  determine  upon  the  diagnosis. 
I  have  more  than  once  had  occasion  to  correct  the  diagnosis  of  other 
practitioners  who  believed  they  had  discovered  a  fracture  of  the 
scapula. 

When  the  line  of  the  fracture  has  traversed  the  spine,  and  any 
considerable  displacement  has  occurred,  one  ought  to  recognize  the 
fracture  easily  by  merely  carrying  the  finger  along  the  crest.  In 
the  example  to  which  Dr.  Neill  called  my  attention  in  the  Pennsylva- 
nia Hospital,  although  there  was  scarcely  any  displacement,  the  point 
of  fracture  could  be  distinctly  felt.  It  is  only  when  the  swelling  over 
the  seat  of  fracture  is  very  great  that  any  difficulty  in  the  diagnosis 
need  to  exist,  or  perhaps  in  the  case  of  a  patient  who  is  very  fat. 

If  the  fracture  has  occurred  through  the  body,  below  or  above  the 
spine,  or  through  either  of  the  angles,  the  displacement  may  not  be  so 
easily  recognized.  The  surgeon  ought  then  to  trace  carefully  with  his 
finger  the  outlines  of  the  scapula,  and  this  he  will  be  able  to  do  more 
satisfactorily  if  he  places  the  scapula  in  such  positions  as  elevate  its 
margins  and  render  them  more  prominent.  In  examining  the  poste- 
rior angle,  the  hand  of  the  injured  limb  may  be  placed  upon  the  oppo- 
site shoulder,  the  forearm  being  carried  across  the  front  of  the  chest ; 
but  in  searching  for  a  fracture  below  the  spine,  the  forearm  ought  to 
be  laid  across  the  back. 

Crepitus,  which  is  not  always  present,  owing  to  the  fact  that  the 
fragments  overlap  completely,  or  because  they  have  been  widely  sepa- 
rated by  the  action  of  the  muscles,  may  generally  be  detected  by 
placing  the  palm  of  the  hand  upon  some  portion  of  the  scapula,  so 
as  to  steady  the  fragment  upon  which  it  rests,  while  the  arm  is  moved 
backwards  and  forwards,  and  in  various  other  directions,  until  their 
broken  surfaces  are  brought  into  contact. 

Some  degree  of  embarrassnjent  in  the  motions  of  the  shoulder  and 
arm  must  always  result  from  this  fracture ;  som.etimes  this  embarrass- 


206 


FRACTUEES  OF  THE  SCAPULA. 


Fig.  50. 


ment  is  very  great,  but  it  ought  not  to  be  considered  ever  as  diagnostic 
of  a  fracture,  since  it  may  be  produced  equally  by  a  severe  contusion; 
and  even  when  it  is  accompanied  with  a  fracture,  it  is  due  rather  to 
the  contusion  than  to  the  fracture. 

Pathology^  seat^  direction,  &c.  Of  incomplete  fractures  of  the  scapula, 
I  have  already  mentioned  that  I  have  seen  one  example. 

Malgaigne  thinks  that  he  has  seen  one  case  of  incomplete  fracture, 
which  occurred  in  a  man  who  was  injured  by  the  fall  of  a  heavy  block  of 
stone,  upon  his  back;  but  as  the  patient  recovered,  his  diagnosis  must 
remain  doubtful.     I  know  of  no  other  recorded  examples. 

Complete  fractures  occur  most  often  below  the  spine,  and  they  are 
generally  oblique  or  transverse,  sometimes  nearly  longitudinal. 

Fractures  involving  the  spine  are  noticed  occasionally,  but  I  am 
not  aware  that  any  one  has  ever  seen  a  specimen  of  a  fracture  of  the 

spine  alone,  although  many  surgeons  have 
spoken  of  them. 

I  have  mentioned  one  example  of  a  frac- 
ture of  the  posterior  angle  as  being  in  the 
cabinet  of  Dr.  Mutter,  of  Philadelphia. 
Malgaigne  seems  to  doubt  its  existence, 
but  speaks  of  it  as  a  fracture  which  sur- 
geons have  "  imagined." 

Occasionally  the  bone  is  broken  into 
more  than  two  fragments. 

As  a  result  of  the  fracture  there  is  usually 
more  or  less  displacement ;  generally,  if 
the  fracture  is  below  the  spine  and  trans- 
verse, and  especially  if  its  direction  is  ob- 
lique from  before  backwards  and  down- 
wards, the  inferior  fragment  is  displaced 
forwards,  or  forwards  and  upwards,  by  the 
action  of  the  serratus  major  anticus,  or  of 
the  teres  major,  while  the  superior  frag- 
ment is  inclined  to  fall  backwards,  and  sometimes  it  is  carried  upwards 
and  backwards,  following  the  action  of  the  rhomboideus  major. 

In  cases  of  comminuted  fracture,  and  occasionally  in  simple  frac- 
tures, the  direction  of  the  displacement  is  reversed,  or  altogether 
changed,  so  that  the  lower  fragment  instead  of  being  in  front  is  behind 
the  upper  fragment,  and  instead  of  overlapping,  the  two  fragments 
are  more  or  less  drawn  asunder.  These  are  deviations  which  are  not 
easily  explained,  but  which  depend,  perhaps,  rather  upon  the  direction 
of  the  blow  than  upon  the  action  of  the  muscles. 

In  a  few  cases  there  is  no  displacement  in  any  direction,  although 
the  crepitus  with  mobility  sufficiently  demonstrates  the  existence  of  a 
fracture. 

Prognosis. — If  displacement  actually  has  taken  place,  it  will  be  found 
very  difficult,  as  we  shall  see  when  we  come  to  consider  the  treatment, 
to  hold  the  fragments  in  apposition,  until  a  cure  is  completed  :  so  that 
they  are  pretty  certain  to  unite  with  a  degree  of  overlapping,  or  other 
irregularity. 


Fractures  of  the  body  and  acromion 
process  of  the  scapula. 


FEACTUEES    OF    THE    BODY    OF    THE    SCAPULA.  207 

Lonsdale,  Lizars,  Chelius,  N^laton,  Gibson,  Malgaigne,  and  others 
have  spoken  of  the  difficulty  or  impossibility  generally  of  keeping 
these  fragments  in  place.  N^laton  and  Malgaigne,  indeed,  confess  that 
they  have  never  succeeded;  Gibson  declares  that  it  is  scarcely  possible; 
while  Chelius  affirms,  that  if  the  fracture  is  near  the  angle  the  cure  is 
always  effected  with  some  deformity. 

But  then  it  is  not  probable  that  the  patient  will  ever  suffer  any 
serious  inconvenience  from  this  irregular  union  of  the  fragments,  since 
the  perfection  of  its  function  depends  less  upon  any  given  form  or  size 
than  in  the  case  of  almost  any  other  large  bone;  and  if,  as  has  been 
observed  by  Lonsdale,  the  free  use  of  the  arm  is  not  recovered  for  some 
time,  or  if,  as  has  been  noticed  by  B.  Bell,  a  permanent  stiffness  results, 
these  should  be  regarded  as  due  to  the  injury  which  those  muscles 
have  suffered  which  envelop  the  scapula,  or  to  some  injury  of  the 
ligaments  and  muscles  which  surround  the  shoulder-joint. 

In  some  few  examples  upon  record,  the  bone  has  been  so  commi- 
nuted, and  the  soft  parts  adjacent  so  much  injured  that  suppuration 
and  necrosis  have  ensued. 

Treatment. — In  the  treatment  of  this  fracture,  the  first  object  with  all 
surgeons  has  been  to  restore  the  fragments  to  place,  and  this  they  have 
chiefly  sought  to  accomplish  by  position ;  after  which,  they  have  en- 
deavored to  immobilize  the  fragments  by  bandages,  &c. 

In  seeking  to  accomplish  the  first  indication,  they  have  placed  the 
shoulder  and  arm  in  a  great  variety  of  postures.  Nearly  all  seem  to 
have  regarded  it  as  of  some  importance  that  the  shoulder  should  be 
elevated,  so  as  to  relax  the  muscles  attached  to  the  upper  and  back 
part  of  the  scapula,  and  thus  permit  the  upper  fragment  to  fall  down- 
wards and  forwards. 

If  we  confine  our  remarks  first  to  fractures  through  the  body,  and 
do  not  include  fractures  of  the  inferior  angle,  this  indication  is  the 
only  one  which  Nekton  and  Mayor  have  sought  to  accomplish,  and 
for  this  purpose  they  employ  a  simple  sling,  while  Amesbury,  Liston, 
Lonsdale,  S.  Cooper,  South,  Skey,  Miller,  Pirrie,  have  added  to  the 
sling  a  bandage  or  roller,  which  is  made  to  inclose  snugly  the  body 
and  arm. 

Erichsen  uses  the  body  bandage  alone,  as  in  fractures  of  the  ribs, 
while  B.  Cooper,  Lizars,  and  Tavernier  employ  a  bandage  which  in- 
closes not  only  the  body,  but  also  the  arm ;  neither  of  these  last-men- 
tioned surgeons  recommends  a  sling,  or  any  other  means  to  elevate 
the  arm. 

Johannes  de  Gorter  advises  that  a  sling  shall  be  used,  but  that  the 
elbow  shall  be  lifted  away  from  the  side  of  the  bod}'-,  so  as  to  relax 
the  deltoid.  Chelius  and  Desault  recommend  the  same  position,  but 
with  the  addition  of  an  axillary  pad,  whose  apex  shall  be  directed 
upwards,  secured  in  place  with  appropriate  bandages. 

Pierre  d'Argelata  used  also  an  axillary  pad,  but  instead  of  a  wedge 
he  recommended  a  simple  roll;  and  instead  of  lifting  the  elbow  away 
from  the  body,  he  directed  that  the  elbow  should  be  secured  against 
the  side,  making  use  of  the  axillary  roll  as  a  fulcrum. 

Petit  and  Heister  advised  that  the  elbow  and  forearm  should  be 


208  FEACTURES    OF    THE    SCAPULA. 

carried  forwards  upon  the  front  of  the  chest,  and  secured  in  this 
position. 

In  the  treatment  of  no  other  fracture  perhaps  have  surgeons  differed 
more  widely  as  to  the  indications  than  in  this,  since,  as  we  have  seen, 
some  recommend  the  elbow  to  be  carried  from  the  body,  and  some  that 
it  shall  be  made  to  approach  the  body ;  one  directs  that  the  elbow 
shall  fall  perpendicularly  beside  the  chest,  a  second  prefers  that  it  shall 
be  carried  a  little  back,  and  a  third  that  it  shall  be  brought  well  for- 
wards. In  one  thing  alone  have  they  nearly  all  agreed,  namely,  that 
the  elbow  shall  be  lifted ;  and  generally  also  it  has  been  recommended 
that  the  arm,  forearm,  and  body  shall  be  confined  by  sufficient  band- 
ages to  insure  quietude.  It  might  be  proper  to  conclude,  therefore, 
that  the  sling  and  bandage  constitute  all  of  the  apparatus  which  is 
necessary  or  useful ;  and  that  it  is  relatively  unimportant  whether  the 
elbow  is  near  or  remote  from  the  body,  or  whether  it  is  in  front  of,  or 
behind,  or  beside  the  chest. 

Such,  indeed,  is  the  conclusion  to  which  we  have  ourselves  arrived ; 
yet  if,  in  relation  to  the  position  of  the  elbow,  a  choice  were  to  be 
expressed,  we  would  give  the  preference  to  that  in  which  the  arm  is 
laid  vertically  beside  the  body,  or,  perhaps,  with  the  elbow  a  little  in- 
clined backwards,  so  as  to  relax  as  completely  as  possible  the  teres 
major. 

It  is  quite  probable,  however,  that  no  single  position  will  be  found 
of  universal  application ;  and  perhaps  it  would  be  more  safe  to  advise 
the  surgeon  in  any  given  case  first  to  reduce  the  fragments  as  com- 
pletely as  possible  by  manipulation,  and  then  to  place  the  arm  in  such 
a  position  as,  upon  careful  experiment  in  this  particular  instance,  he 
shall  find  enables  him  to  best  retain  them  in  place. 

If,  however,  the  fracture  is  such  as  to  have  separated  the  inferior 
angle  from  the  body,  it  will  be  well  to  follow  the  advice  of  Boyer  and 
of  others,  and  to  place  a  compress  in  front  of  the  inferior  angle  to 
resist  the  greater  tendency  to  displacement  in  this  direction.  This 
compress  will  more  effectually  accomplish  this  indication  if  the  roller 
with  which  it  is  secured  to  the  body,  and  with  which  we  seek  to  im- 
mobilize the  scapula  and  chest,  is  turned  from  before  backwards,  or 
in  a  direction  of  antagonism  to  the  action  of  the  muscles  which  pro- 
duce the  displacement. 

Desault,  with  Chelius  and  Bransby  Cooper,  has  recommended  also, 
in  the  case  of  a  fracture  through  the  angle,  that  the  forearm  should 
be  acutely  flexed  upon  the  arm,  and  that  the  hand  should  be  placed  in 
front  of  the  chest,  upon  the  sound  shoulder,  a  position  which  is  always 
irksome,  and  sometimes  insupportable,  and  which  does  not  offer  in  any 
case  sufficient  advantages  to  render  it  worthy  of  a  trial. 


§  2.  Fractures  of  the  Neck  of  the  Scapula. 

If  by  "the  neck  of  the  scapula,"  surgeons  mean  that  slightly 
constricted  portion  of  this  bone  which  is  situated  at  the  base  of  the 
glenoid  cavity,  and  it  is  to  this  portion,  we  believe,  that  anatomists 


FRACTURES    OF    THE    NECK    OF    THE    SCAPULA, 


209 


Fig.  51. 


Comminuted  fracture  of  tl  o 
glenoid  cavity. 


have  generally  applied  the  term  "neck,"  then  its  fracture  is  cer 
tainly  very  rare.  Indeed,  its  existence,  uncomplicated  with  a 
comminuted  fracture  of  the  glenoid  cavity,  is 
denied  by  Sir  Astley  Cooper,  South,  Erichsen, 
and  others.  Mr.  South  says  there  is  no  such 
specimen  in  any  of  the  museums  in  London;  and 
1  have  not  been  able  to  find  one  in  any  of  the 
American  cabinets.  Dr.  Mott  has  said  to  me  that 
he  had  never  seen  a  specimen,  and  that  in  the 
natural  condition  of  the  bone  he  regards  its  oc- 
currence as  impossible.  Such,  I  confess,  also,  is 
my  own  conviction. 

If,  however,  it  is  intended,  in  speaking  of  frac- 
tures of  the  neck  of  the  scapula,  to  refer,  as  Sir 
Astley  Cooper  has  done,  only  to  fractures  extend- 
ing through  the  semilunar  notch,  behind  the  root 
of  the  coracoid  process,  then  its  existence  is  cer- 
tain ;  yet  the  fracture  is  not  common.  Duverney 
has  reported  one  example,  the  existence  of  which 
he  established  by  a  dissection.  The  coracoid 
process  was  broken  at  the  same  time,  but  the 
fracture  through  what  was  called  the  neck,  was 
distinct  from  this:  and  Sir  Astley  has  recorded 
three  examples  in  which  the  diagnosis  was  very  clearly  made  out,  yet 
not  actually  proven  by  an  autopsy. 

Symptoms. — Sir  Astley  justly  remarks  that  "the  degree  of  deformity 
produced  by  this  accident  depends  upon  the  extent  of  laceration  of  a 
ligament  which  passes  from  the  under 
part  of  the  spine  of  the  scapula  to  the 
glenoid  cavity.  If  this  be  torn"  (and 
to  this  we  ought  to  add  the  ligaments 
passing  from  the  coracoid  process  to 
the  clavicle  and  acromion  process)  "  the 
glenoid  cavity  and  the  head  of  the  os 
humeri  fall  deeply  into  the  axilla,  but 
the  displacement  is  much  less  if  this 
remains  whole." 

The  usual  signs  are,  a  depression 
under  the  acromion  process,  the  same 
as  in  dislocation  of  the  head  of  the 
humerus  downwards,  but  not  so  deep; 
the  head  of  the  humerus  felt,  perhaps,  in 
the  axilla ;  crepitus,  and  the  immediate 
recurrence  of  the  displacement  when- 
ever, after  the  reduction  has  been  fairly 
accomplished,  the  arm  is  left  unsup- 
ported. The  crepitus  is  best  discovered 
by  resting  one  hand  upon  the  top  of  the  shoulder  in  such  a  manner 
as  that  a  finger  shall  touch  the  point  of  the  process,  while  the  arm  is 
rotated  and  moved  up  and  down  by  the  opposite  hand.  It  may  also 
14 


Fig.  52. 


Fracture  of  the  neck  of  the  scapula  ;  ac- 
cording to  A.  Cooper. 


210  FEACTUEES    OF    THE    SCAPULA. 

be  easily  ascertained  that  the  coracoid  process  moves  with  the  humerus 
instead  of  the  scapula.  Occasionally,  the  accident  is  accompanied 
with  paralysis  of  the  arm,  from  pressure  upon  the  axillary  nerves,  and 
a  rupture  of  the  axillary  artery  is  also  mentioned  by  Dugas.^ 

Treatment. — The  indications  of  treatment  are  three,  namely,  to  carry 
the  head  of  the  humerus,  with  the  glenoid  cavity,  &c.,  up,  to  carry  it 
out,  and  to  confine  the  body  of  the  scapula.  The  first  is  accomplished 
by  a  sling,  the  second,  by  a  pad  in  the  axilla,  and  the  third  by  a  broad 
roller  carried  repeatedly  around  the  arm  and  chest  and  across  the 
shoulder. 

§  3.  Fractures  of  the  Acromion  Process. 

Examples  of  fracture  of  the  acromion  process  have  been  reported 
by  Duverney,  Bichat,  Avrard,  A.  Cooper,  Desault,  Sanson,  N^laton, 
Malgaigne,  West,^  Brainard,^  Stephen  Smith,"  and  others.  I  have 
myself  seen  three  examples.* 

In  the  case  seen  by  Cooper  it  entered  the  articulation  of  the  clavicle, 
and  produced  at  the  same  moment  a  dislocation.  Malgaigne  says  it 
occurs  generally  farther  up,  and  posterior  to  the  attachments  of  the 
clavicle,  "near  the  junction  of  the  diaphysis  with  the  epiphysis,"  and 
that  the  fracture  is  in  most  cases  transverse  and  vertical ;  but  N^laton 
saw  a  case  in  which  the  fracture  was  oblique.  In  the  case  reported 
by  C.  West,  of  Hagerstown,  Md.,  the  fracture  was  through  the  base 
of  the  process.  In  two  of  the  examples  seen  by  me  the  fracture  was 
in  front  of  the  clavicle;  and  in  the  third,  occasioned  by  the  fall  of  a 
barrel  of  flour  upon  the  shoulder,  the  fracture  occurred  at  the  acromio- 
clavicular articulation,  and  was  accompanied  with  an  upward  disloca- 
tion of  the  outer  end  of  the  clavicle. 

There  is  some  reason  to  believe,  I  think,  that  a  true  fracture  of  the 
acromion  process  is  much  more  rare  than  surgeons  have  supposed, 
and  that  in  a  considerable  number  of  the  cases  reported  there  was 
merely  a  separation  of  the  epiphysis ;  the  bony  union  having  never 
been  completed.  If  such  fractures  or  separations  occurred  only  in 
children,  very  little  doubt  might  remain  as  to  the  general  character  of 
the  accident :  but  the  specimens  which  I  have  found  in  the  museums, 
and  the  cases  reported  in  the  books,  have  been  mostly  from  adults. 
It  is  more  difficult,  therefore,  to  suppose  these  to  be  examples  of  separa- 
tions of  epiphyses,  but  I  am  inclined  to  think  that  in  a  majority  of  in- 
stances such  has  been  the  fact.  It  is  very  probable,  also,  that  in  the 
case  of  many  of  the  specimens  found  in  the  museums,  called  fractures, 
the  histories  of  which  are  unknown,  they  were  united  originally  by  car- 
tilage, and  that  in  the  process  of  boiling,  or  of  maceration,  the  disjunc- 
tion has  been  completed.  The  narrow  crest  of  elevated  bone  which 
frequently  surrounds  the  process  at  the  point  of  separation,  and  which 

'  Remarks  on  Frac.  of  Scapula,  by  L.  A.  Dugas,  Georgia.  Am.  Journ.  Med.  Sei., 
Jan.  1858. 

"'  West,  Penin.  Jonrn.  of  Med.,  vol.  v.  p.  254. 

'  Brainard,  Bost.  Med.  and  Surg.  Journ.,  vol.  xxxi.  p.  501. 

*  *  S.  tmith.     Hamilton,  Report  on  Deform.,  op.  cit. 


FEACTUEES  OF  THE  ACEOMION  PEOCESS.        211 

Malgaigne  may  have  mistaken  for  callus,  is  found  upon  very  many 
examples  of  undoubted  epiphyseal  separations  which  I  have  examined; 
and  this  circumstance,  no  doubt,  has  tended  to  strengthen  the  suspicion 
that  these  were  cases  of  fracture. 

This  opinion  is  confirmed  by  the  remark  of  Mr.  Fergusson,  that  a 
fracture  of  this  process  is  an  accident  "  of  rare  occurrence."  "  I  have 
dissected,"  he  adds,  "  a  number  of  examples  of  apparent  fracture  of  the 
end  of  this  process;  but  in  such  instances  it  is  doubtful  if  the  movable 
portion  had  ever  been  fixed  to  the  rest  of  the  bone."  But  the  most 
complete  explanation  is  furnished  by  that  distinguished  pathologist  Dr. 
J.  B.  S.  Jackson,  of  Boston,  who  observes  that  this  process  ossifies  in 
two  pieces,  instead  of  one,  as  has  usually  been  stated  by  anatomists ;  so 
that  we  may  find  an  example  of  a  short  epiphysis  or  of  a  long  one,  a 
difterence  which  many  of  the  cabinet  specimens  present,  although  the 
usual  length  is  about  three-quarters  of  an  inch.  These  two  extreme 
points  of  ossification  first  coalesce,  and  then  unite  with  the  body.  Dr. 
Jackson  says,  moreover,  that  there  are  four  specimens  in  the  museum 
of  the  Massachusetts  Medical  College,  and  in  the  museum  of  the 
Boston  Society  for  Medical  Improvement,  which  might  easily  be  mis- 
taken for  fractures,  but  which  only  illustrate  to  how  late  a  period  the 
bony  union  is  sometimes  delayed.  In  one  specimen  the  patient  could 
not  have  been  less  than  forty  years  of  age ;  "  the  acromial  process  of 
each  scapula  was  fully  formed,  but  having  no  bony  union  whatever 
with  the  bone  itself.  The  union  was  ligamentous,  but  strong  and 
close."^ 

To  the  same  class  belong  several  specimens  in  my  own  collection  ; 
specimens  163  and  997  in  Dr.  March's  collection ;  707  in  the  Albany 
College  collection ;  two  specimens  in  the  Mutter,  and  one  in  the  Jef- 
ferson Medical  College  museums. 

I  wish  to  mention,  also,  that  in  the  case  of  my  own  specimens  of 
epiphyseal  separation,  as  well  as  most  of  the  specimens  which  I  have 
examined,  the  ends  of  the  fragments  were  closed  with  a  compact  bony 
tissue. 

No  doubt,  however,  a  fracture  of  this  process  does  occasionally  take 
place.  In  addition  to  my  ow^n,  I  have  already  mentioned  several 
other  examples,  some  of  which  have  been  confirmed  by  dissection: 
and  in  the  case  mentioned  by  Stephen  Smith,  an  autopsy,  made  three 
weeks  after  the  accident,  showed  a  fracture  without  displacement,  the 
periosteum  covering  its  upper  surface  not  being  torn ;  the  fragment 
could  be.  turned  back  as  upon  a  hinge. 

Prognosis. — The  process  generally  unites  with  a  slight  downward 
displacement.  This  occurred  in  at  least  two  of  the  examples  seen  by 
me ;  but  in  such  cases  the  motions  of  the  arm  are  not  in  consequence 
much,  if  at  all,  embarrassed ;  unless,  indeed,  it  is  so  much  depressed 
as  to  interfere  with  the  upward  movements  of  the  arm;  a  result  which 
Heister  erroneously  supposed  was  inevitable. 

Sir  Astley  Cooper  says  that  a  true  bony  union  is  rare  in  these  frac- 
tures, and  that  there  generally  results  a  false  joint,  the  fragments 

'  The  author's  Report  on  Deform.,  &c.,  op.  cit. 


212  FEACTURES    OF    THE    SCAPULA.  p 

uniting  by  a  fibrous  tissue;  but  sometimes  the  surfaces,  instead  of 
uniting  either  by  bone  or  ligament,  become  polished,  and  even  ebur- 
nated, 

Malgaigne  has  noticed,  also,  in  a  specimen  contained  in  the  Dupuy- 
tren  museum,  a  hypertrophy  of  the  lower  fragment,  this  portion  having 
a  diameter  nearly  twice  as  great  as  that  of  the  portion  from  which  it 
was  detached. 

Symptoms. — Where  no  displacement  exists,  the  diagnosis  must 
always  be  difficult,  if  not  impossible.  In  such  a  case  Ave  could  only 
be  instructed  by  the  manner  in  which  the  injury  had  been  received, 
by  the  contusion,  and  by  the  presence  of  mobility  or  crepitus. 

In  examples  attended  with  displacement,  if  no  swelling  is  present, 
the  finger  carried  along  the  spine  of  the  scapula-  to  its  extremity,  will 
easily  detect  the  fracture  by  the  abrupt  termination  of  the  process,  or 
by  the  presence  of  a  fissure,  or  a  depression ;  but  as  to  the  other  symp- 
toms, they  must  depend  very  much  upon  the  point  at  which  the 
fracture  has  taken  place.  If  in  front  of  the  acromio-clavicular  articu- 
lation, the  position  of  the  arm  in  its  relations  to  the  body  will  not  be 
changed ;  but  if  the  fracture  is  through  the  articulation,  and  a  dis- 
location of  the  clavicle  results,  or  if  it  is  behind  the  acromio-clavicular 
articulation,  the  arm,  having  in  either  case  lost  the  support  of  the 
clavicle,  will  assume  the  same  position  that  it  does  in  a  fracture  of 
the  clavicle;  that  is,  the  shoulder  will  fall  downwards,  inwards,  and 
forwards. 

Treatment. — If  the  fracture  has  taken  place  in  front  of  the  acromio- 
clavicular articulation,  no  doubt  the  most  rational  plan  of  treatment  is 
that  recommended  by  Delpech ;  that  is,  placing  the  patient  in  bed, 
upon  his  back,  and  carrying  the  arm  out  from  the  body  nearly  to  a 
right  angle ;  since  by  this  method  the  fragment  is  not  only  lifted,  but 
the  deltoid  muscle  is  relaxed,  and,  consequently,  the  fragment  is  no 
longer  forcibly  drawn  away  from  the  spine  of  the  scapula.  If,  there- 
fore, the  patient  will  submit  to  this  treatment  for  a  sufficient  length  of 
time,  the  union  must  be  accomplished  with  the  least  possible  amount 
of  displacement.  In  case  he  will  not  consent  to  such  confinement,  I 
am  confident  no  other  plan  which  has  been  recommended  merits  a 
trial,  unless  it  be  simply  to  place  the  arm  in  a  sling  until  the  union  is 
accomplished. 

If,  however,  the  fracture  has  taken  place  at,  or  behind  the  junction 
of  the  clavicle  with  the  process,  the  indications  of  treatment  must  be 
in  all  respects  the  same  as  in  a  fracture  of  the  clavicle. 


§  4.  Fractures  of  the  Coracoid  Process. 

I  am  surprised  that  Mr.  Lizars  should  have  never  seen  a  case,  or 
heard  of  a  well  authenticated  example  of  a  fracture  of  the  coracoid 
process.  "  The  coracoid  process,"  he  remarks,  "  is  said  to  be  broken 
oflj  but  this  I  question  very  much ;  it  must  be  along  with  the  glenoid 
cavity,  or  there  must  be  a  fracture  of  the  neck  of  the  scapula." 

Dr.  Neill,  of  Philadelphia,  has  in  his  cabinet  a  specimen  of  separa- 


FRACTURES  OF  THE  CORACOID  PROCESS.        213 

tion  of  this  process  at  about  one  inch  from  its  extremity.  The  line  of 
separation  is  somewhat  irregular;  there  is  no  callus,  but  it  is  united 
to  the  upper  portion  by  a  dried  tissue,  half  an  inch  in  length,  and  con- 
tinuous with  the  periosteum.  This  has  been  regarded  as  an  example 
of  fracture ;  but  although  the  scapula  is  large  and  evidently  belongs  to 
an  adult,  the  fact  that  the  acromion  process  is  not  yet  united  by  bone, 
renders  it  probable  that  this,  also,  is  an  epiphyseal  separation.  Prof. 
Charles  Gibson,  of  Richmond,  Va.,  informs  me  also  that  he  has  in  his 
cabinet  a  dried  specimen,  from  an  adult,  which  has  been  broken  ob- 
liquely near  the  end,  but  which  is  now  united  by  a  ligamentous  or 
fibrous  tissue  of  one  line  and  a  half  in  length.  The  fragment  is  dis- 
placed a  little  forwards,  as  well  as  downwards.  Reuben  D.  Mussey, 
of  Cincinnati,  is  in  possession  of  a  very  remarkable  and  conclusive  ex- 
ample of  this  fracture.  The  humerus  is  dislocated  forwards,  the  head 
and  neck  being  firmly  united  to  the  neck  and  venter  of  the  scapula, 
while  at  the  same  time  the  coracoid  process  is  broken  and  displaced. 
Dr.  Jackson,  of  Boston,  says  that  specimen  Ko.  453  in  the  museum  of 
the  Massachusetts  Medical  College,  seems  clearly  to  have  been  a  frac- 
ture involving  the  base  of  the  coracoid  process,  and  which,  having 
taken  place  somewhere  within  a  year  of  the  death  of  the  person,  had 
become  united  by  bone,  and  that  just  before  death  the  process  had 
broken  off,  and  so  completely,  as  to  involve  a  portion  of  the  glenoid 
cavity.' 

Bransby  Cooper  relates  a  case  of  fracture  through  the  bnse,  which 
after  eight  weeks,  when  the  patient  died,  was  found  to  be  united  by  a 
ligament.  The  acromion  process  was  broken  at  the  same  time,  and 
had  united  in  the  same  manner.  The  head  of  the  humerus  was  also 
broken  and  partly  united.^  One  example  is  said  to  have  occurred  in 
the  practice  of  Dr.  Arnott,  at  the  Middlesex  Hospital,  London,  in 
consequence  of  which  the  patient  died,  when  a  dissection  disclosed 
the  true  nature  of  the  accident.'  Mr.  South  has  also  reported  a  case 
lesembling  somewhat  Mussey 's,  but  much  more  complicated.  The 
humerus  was  partially  dislocated  forwards,  the  clavicle,  acromion  pro- 
cess, and  the  olecranon  were  broken  as  well  as  the  coracoid  process. 
Neither  the  fracture  of  the  clavicle  nor  of  the  coracoid  process  were 
made  out  until  after  the  patient  died,  which  was  on  the  fourth  day; 
the  fact  of  the  existence  of  these  fractures  being  then  ascertained  by 
dissection.'*  Erichsen  says  there  is  in  the  museum  of  the  University 
College,  a  preparation  showing  a  fracture  at  the  base  of  this  process, 
the  line  of  fracture  extending  across  the  glenoid  cavity.*  Duverney, 
Boyer,  and  Malgaigne,  have  also  reported  four  additional  examples 
confirmed  by  dissections.^ 

The  existence  of  this  form  of  fracture,  established  by  at  least  nine 
or  ten  dissections,  can  no  longer  be  denied ;  yet  it  is  usually  accom- 
panied with  serious  complications,  such  as  must  in  most  cases  prove 

'  The  author's  Report  on  Deformities,  op.  cit. 

^  B.  Cooper,  edition  of  Sir  Astley  on  Frac.  and  Disloc,  Amer.  ed.,  p.  380. 

^  Arnott,  Feruu^son's  Surg.,  p.  213. 

'  South,  Loud.  Med.-Chir.  Rev.,  1840,  vol.  xxxii.,  new  ser.,  p.  41. 

'"  Eriubsen,  Surgery,  p.  207.  ^  Malgaigne,  op.  cit.,  p.  512. 


2U 


FRACTUEES    OF    THE    SCAPULA. 


fatal.  In  the  only  case,  however,  in  which  I  have  had  reason  to 
believe  that  I  had  to  deal  with  a  fracture  of  this  kind,  the  symptoms 
and  termination  were  less  grave,  although  it  was  complicated  with 
an  upward  dislocation  of  the  outer  end  of  the  clavicle.  A  gentleman 
residing  in  this  county  was  struck  by  a  board  which  fell  edgewise 
upon  his  shoulder.  The  fracture  of  the  coracoid  process  does  not 
seem  to  have  been  recognized  by  his  surgeon.  An  apparatus  was  ap- 
plied to  retain  the  clavicle  in  its  place,  but  after  three  months,  when 
he  called  upon  me,  it  still  remained  displaced  as  at  first.  During  all 
of  this  time  the  apparatus  had  been  steadily  kept  on.  On  laying  off 
the  dressings  I  discovered  that  the  coracoid  process  was  detached, 
obeying  constantly  the  movements  of  the  head  of  the  humerus,  but 
being  not  at  all  subject  to  the  movements  of  the  scapula.  Some  months 
later  I  examined  the  arm  again,  and  found  the  parts  in  the  same  con- 
dition as  before,  but  the  functions  of  the  arm  were  not  impaired. 

It  has  been  generally  stated  that  when  this  process  is  broken  off,  it 
will  be  carried  downwards  by  the  united  action  of  the  pectoralis 

minor,  the  short  head  of  the  biceps, 
and  the  coraco-brachialis  muscles; 
but  this  will  depend  upon  whether 
the  coraco-clavicular  ligaments  are 
ruptured  also;  a  circumstance  which 
is  not  very  likely  to  occur,  at  least 
to  any  great  extent ;  and  in  fact  not 
one  of  the  well-attested  examples  of 
this  fracture  have  ever  been  accom- 
panied with  any  considerable  dis- 
placement in  this  direction. 

Treatment. — In  case  of  a  simple 
fracture  of  the  process  unattended 
with  any  other  lesions,  it  is  suflficient 
to  place  the  arm  in  a  sling  with  the 
elbow  advanced  as  much  as  possible 
upon  the  front  of  the  chest ;  as  by 
this  position  we  relax  somewhat  all  of  the  three  muscles  having  attach- 
ments to  this  process.  If  we  were  to  add  anything  to  this  simple 
procedure  it  would  be  merely  to  confine  the  scapula  by  a  few  turns 
of  a  roller.  It  is  not  probable,  however,  that  by  either,  or  both  of 
these  measures  we  should  accomplish  enough  to  justify  their  continu- 
ance if  they  were  found  to  be  painful,  or  even  exceedingly  irksome. 

In  the  graver  forms  of  the  accident,  where  other  bones  about  the 
shoulder  are  broken  or  dislocated,  which,  as  we  have  seen,  constitute 
the  largest  proportion  of  the  whole  number,  the  treatment  must  gene- 
rally have  little  or  no  regard  to  this  particular  injury. 


Fracture  of  the  coracoid  process. 


FRACTURES    OF    THE    HUMERUS.  215 


CHAPTER    XX. 

FRACTURES    OF    THE   HUMERUS. 

It  is  not  sufficient  to  consider  fractures  of  this  bone  as  occurring 
through  the  shaft  and  its  two  extremities,  as  some  systematic  writers 
have  done  ;  since  upon  this  simple  arrangement  it  is  impossible  to 
base  a  natural  division  of  their  causes,  symptoms,  prognosis,  and  treat- 
ment. 

We  shall  find  it  necessary  to  consider, 

1.  Fractures  of  the  head  and  anatomical  neck.  (Tntra-capsular;  non- 
impacted  and  impacted.) 

2.  Fractures  through  the  tubercles.  (Extracapsular ;  non-impacted 
and  impacted.) 

3.  Longitudinal  fractures  of  the  head  and  neck,  or  splitting  off  of 
the  greater  tubercle. 

4.  Fractures  of  the  surgical  neck.  (Including  separations  at  the 
upper  epiphysis.) 

5.  Fractures  through  the  body  of  the  shaft,  or,  of  the  shaft  below 
the  surgical  neck  and  above  the  base  of  the  condyles. 

6.  Fractures  at  the  base  of  the  condyles.  (Including  separations  at 
the  lower  epiphysis.) 

7.  Fractures  at  the  base,  complicated  with  fractures  between  the 
condyles,  extending  into  the  joint. 

8.  Fractures  or  separations  of  the  internal  epicondyle. 

9.  Fractures  or  separations  of  the  external  epicondyle. 

10.  Fractures  of  the  internal  condyle. 

11.  Fractures  of  the  external  condyle. 

Of  90  fractures  of  the  humerus  examined  by  me,  16  occurred  through 
the  upper  third,  15  through  the  middle  third,  and  59  through  the 
lower  third.  Or,  if  we  reject  fractures  of  the  head  and  neck,  and  frac- 
tures of  the  condyles,  and  confine  our  analysis  to  the  shaft,  12  belong 
to  the  upper  third,  15  to  the  middle  third,  and  27  to  the  lower  third. 
An  observation  which  is  in  contrast  with  the  statement  made  by 
Amesbury,  and  which  has  been  repeated  by  Lizars,  B.  Cooper,  Fer- 
gusson,  Gibson,  and  others,  that  this  bone  is  most  often  broken  in  its 
middle  third. 

Of  the  fractures  belonging  to  the  upper  third,  one  was  a  separation 
at  the  junction  of  the  epiphysis  with  the  shaft,  one  was  probably  a 
fracture  at  or  near  the  anatomical  neck,  with  implaction  and  splitting 
of  the  tubercles,  one  was  a  fracture  of  the  greater  tubercle  alone,  and 
eight  were  fractures  of  the  surgical  neck. 

Of  the  fractures  belonging  to  the  lower  third,  14  were  through  the 
internal  condyle  and  epicondyle,  14  through  the  external  condyle,  14 
were  at  the  base  of  the  condyles,  and  4  through  the  condyles  and 


216 


FEACTUEES    OF    THE    HUMEEUS. 


across  the  base  at  the  same  time.  The  remainder,  13,  being  through 
the  shaft,  but  above  the  base. 

Unfortunately,  surgical  writers  have  not  been  agreed  in  the  use  and 
application  of  the  terms  "head,"  "neck,"  "anatomical  neck,"  and  "sur- 
gical neck"  of  the  humerus ;  and,  as  a  consequence,  their  meaning  is 
often  obscure,  and  their  teachings  are  sometimes  contradictory  and 
absurd.'  It  is  necessary,  therefore,  that  we  should  define  them  more 
precisely. 

The  head  of  the  humerus  is  that  smooth,  elliptical  surface,  covered 
by  cartihige  and  synovial  membrane,  which  articulates  with,  and  is 
received  into  the  glenoid  cavity  of  the  scapula. 

The  anatomical  neck  is  the  narrow  line  immediately  encircling  the 
head,  and  which  receives  the  insertion  of  the  capsular  ligament. 

The  surgical  neck  is  that  portion  which  commences  at  the  lower 
margin  of  the  tubercles,  or  at  the  point  of  junction  between  the  epi- 
physis and  the  diaphysis,  and  which  terminates  at  the  insertion  of  the 
pectoralis  major  and  latissimus  dorsi. 

The  neck  is  all  of  that  portion  included  between  the  head  and  the 
insertion  of  the  pectoralis  major  and  latissimus  dorsi,  comprising  not 
only  the  anatomical  and  surgical  necks,  but  also  the  tubercles,  which 
occupy  the  triangular  space  between  these  two. 


Fig.  54. 


§  1.  Fractures  OF  THE  Head  and  Anatomical  Neok.     (Intra-capsular  ; 
Non-impacted,  and  Impacted.) 

Onuses. — The  causes  which  have  been  found  competent  to  produce 
fractures  of  the  head  and  anatomical  neck  are,  the  penetration  of  balls 
or  of  other  missiles  directly  into  the  joint,  producing 
thus  a  compound,  and  generally  comminuted  frac- 
ture of  the  head ;  or  falls,  or  direct  blows  upon  the 
shoulder  without  penetration. 

Pathology,  Results,  &c. — When  the  fracture  re- 
sults from  the  direct  penetration  of  some  foreign 
body  into  the  joint,  it  is  not  only  a  compound  frac- 
ture, but  the  head  of  the  bone  is  almost  necessarily 
broken  into  fragments.  These  accidents  are  gene- 
rally fatal ;  not  so  much  from  the  peculiar  nature 
of  the  injury,  as  from  the  severity  of  the  blow  re- 
quisite for  their  production,  and  from  the  compli- 
cations which  usually  attend  them.  If  the  patients 
recover,  sooner  or  later  the  fragments  have  gene- 
rally to  be  removed. 

Fractures  of  the  anatomical  neck,  produced  by 
falls  upon  the  shoulder  without  penetration,  are, 
however,  usually  neither  compound  nor  commi- 
nuted, but  they  often  follow,  with  a  remarkable 
degree  of  accuracy,  the  line  of  the  insertion  of  the 
capsular  ligament,  being  always,  according  to  Eobert  Smith,  within 


Fracture  of  the  anato 
mical  neck. 


'  Boston  Med.  and  Surg.  Journ.,  June  24,  1858,  p.  410. 


FRACTUEES    OF    THE    HEAD    AXD    ANATOMICAL    NECK.      217 

the  inferior  or  outer  margin  of  this  insertion.  He  calls  them,  there- 
lore,  intra-capsular.  It  is  probable,  however,  since,  as  we  shall  pre- 
sently see,  bony  union  is  not  denied  to  this  fracture,  that  the  line  of 
separation  is  not  always,  or  generally,  perhaps,  completely  within  the 
insertion  of  the  ligament,  but  that  it  is  in  some  degree  extra- articular, 
if  not  extra-capsular.  If  it  is  entirely  intra-articular,  no  doubt  union 
of  the  fragments  can  never  take  place,  and  generally  suppuration  will 
ensue,  demanding,  at  a  period  not  very  remote,  an  operation  for  their 
removal,  the  same  as  in  compound  fractures.  Dr.  Daniel  Brainard,  of 
Chicago,  informs  me  that  he  has  twice  had  occasion  to  open  the 
shoulder-joint  for  the  removal  of  the  head  of  the  bone,  rendered  neces- 
sary bv  the  suppuration  resulting  from  severe  injuries.  In  the  first 
case,  i)r.  Brainard  removed  the  fragment  about  one  year  after  the 
accident.  It  was  "  loose,  necrosed,  and  partly  absorbed  or  macerated." 
In  the  second  case  the  operation  was  made  about  three  months  after 
the  receipt  of  the  injury.  Both  have  recovered,  with  pretty  useful 
arms. 

Gibson,  however,  thinks  that  the  fragment  occasionally  remains, 
being  gradually  absorbed  and  changed  in  figure.  He  says  that  his 
museum  contains  three  or  four  well-marked  cases  of  this  kind,  in  all 
of  which  the  head  has  lost  its  spherical  form,  and  is  very  much  di- 
minished, and  rough  and  flattened  next  to  the  scapula.'  Other  cabinets 
contain  similar  specimens. 

The  displacements  to  which  the  upper  fragment,  or  the  head  of  the 
bone,  is  subject,  are  remarkable,  and  some  of  them  do  not  seem  to  be 
satisfactorily  explained.  Frequently,  indeed,  its  position  is  not  sensi- 
bly disturbed,  but  at  other  times  it  is  found  impacted,  or  driven  into 
the  cancellous  structure  of  the  inferior  fragment,  in  consequence  of 
which  one  or  both  of  the  tubercles  are  frequently  broken  off. 

Eobert  Smith  relates  the  following  case  as  having  aftbrded  him  his 
■first  opportunity  of  ascertaining,  by  post-mortem  examination,  the 
exact  nature  of  this  form  of  displacement: — 

"  A  female,  set.  47,  was  admitted  into  the  Richmond  Hospital  under 
the  care  of  the  late  Dr.  McDowell,  for  an  injury  to  the  humerus,  the 
result  of  a  fall  upon  the  shoulder.  Five  years  afterwards,  the  woman 
was  again  admitted,  under  the  care  of  Mr.  Adams,  with  an  extra-cap- 
sular fracture  of  the  neck  of  the  femur,  one  mouth  after  the  occurrence 
of  which  she  died,  in  consequence  of  an  attack  of  diarrhoea. 

"  The  shoulder  was  of  course  carefully  examined ;  the  arm  was 
slightly  shortened,  the  contour  of  the  shoulder  was  not  as  full  or 
round  as  that  of  its  fellow,  and  the  acromion  process  was  more  promi- 
nent than  natural.  Upon  opening  the  capsular  ligament,  the  head  of 
the  humerus  was  found  to  have  been  driven  into  the  cancellated  tissue 
of  the  shaft,  between  the  tuberosities,  so  deeply  as  to  be  below  the 
level  of  the  summit  of  the  greater  tubercle  ;  this  process  had  been  split 
off  and  displaced  outward ;  it  formed  an  obtuse  angle  with  the  outer 
surface  of  the  shaft  of  the  bone."^ 

The  description  is  accompanied  with  two  excellent  drawings  of  the 

'  Gibson,  Elements  of  Surgery,  vol.  i.  p.  279. 

2  R.  Smith,  Fractures  iu  Vicinity  of  Joints,  pp   191-3. 


218  FEACTUEES    OF    THE    HUMEEUS. 

specimen,  showing  the  distance  to  which  the  superior  fragment  had 
penetrated  the  inferior,  and  showing  also  complete  union  bj  bone. 

I  believe,  also,  that  in  the  following  example  there  was  a  fracture 
at  or  near  the  anatomical  neck,  with  impaction,  and  splitting  of  the 
tubercles : — 

January  12,  1858,  a  young  man,  aged  about  sixteen  years,  fell  from 
a  height  in  a  gymnasium,  severely  injuring  his  left  shoulder.  I  saw 
him,  with  Dr.  Boardman,  soon  after  the  accident,  and  found  him  com- 
plaining very  much  of  the  shoulder,  which  was  some  swollen  and 
tender.  He  could  not  tell  us  how  he  fell,  nor  could  we  discover  any 
contusions  by  which  to  determine  the  point  where  the  blow  was  re- 
ceived. All  motions  of  the  shoulder-joint  were  painful ;  and  there 
was  a  remarkable  fulness  in  front  of  the  joint,  feeling  like  the  head  of 
the  bone,  yet  not  such  as  is  usually  present  in  a  forward  luxation.  To 
determine  this  more  positively,  however,  the  limb  was  manipulated  as 
for  the  reduction  of  a  dislocation.  Once  during  the  manipulation  a 
feeble  but  distinct  crepitus  was  detected;  yet  the  position  of  the  bone 
remained  unchanged.  The  head  was  found  to  be  in  the  socket,  but 
the  precise  nature  of  the  injury  was  not  made  out. 

Fifteen  days  later,  when  the  swelling  had  completely  subsided,  a 
careful  examination  was  again  made  by  Dr.  Boardman  and  myself, 
when  we  arrived  at  the  conclusion  that  it  was  a  fracture  through  the 
bicipital  groove,  and  that  the  lesser  tubercle  was  carried  forward  half 
an  inch  or  more  from  its  fellow,  while  the  head  with  the  greater  tu- 
bercle, occupied  their  natural  positions  opposite  the  socket.  The 
fragment  projecting  in  front  presented  a  sharp  point,  and  could  not  be 
confounded  with  any  swelling  of  the  soft  parts.  There  was  a  distinct 
space  between  the  tubercles,  into  which  the  finger  could  be  laid.  No 
depression  existed  under  the  acromion  process  behind,  but  on  mea- 
surement the  head  of  this  humerus  was  found  to  be  half  an  inch  wider 
in  its  antero-posterior  diameter  than  the  opposite. 

That  this  fracture  was  accompanied  with  impaction  was  rendered 
certain  by  the  repeated  and  careful  measurements  of  the  length  of  the 
humerus,  which  constantly  showed  a  shortening  of  half  an  inch. 

Under  these  circumstances  union  generally  takes  place ;  but  it  is 
usually  accompanied  with  the  formation  of  an  irregular  mass  of  osteo- 
phytes, which  encircle  the  head  like  a  coronet;  presenting  in  this 
respect  again  a  remarkable  resemblance  to  extra-capsular  fractures  of 
the  neck  of  the  femur.  This  ensheathing  callus,  as  it  may  be  called, 
is  an  outgrowth  from  the  inferior  fragment,  and  it  sometimes  incloses 
the  upper  fragment  as  the  case  of  a  watch  incloses  the  crystal,  only  in 
a  manner  much  more  irregular,  thus  retaining  it  steadily  in  its  place, 
although  very  little  direct  union  has  occurred.  The  cancellous  tissue, 
nevertheless,  is  occasionally  found  united  completely  by  a  new  and 
intermediate  bony  tissue,  and  at  other  times  by  a  fibrous  tissue,  or  by 
both  fibrous  and  bony  tissue. 

In  some  cases  a  perfect  false  joint  has  been  formed  between  the 
opposing  surfaces,  while  in  a  few  unfortunate  examples  the  head  not 
only  refuses  to  unite,  but  by  its  presence,  as  we  have  already  remarked, 
produces  inflammation  and  suppuration,  resulting  in  its  final  extrusion 


FRACTUEES    OF    THE    HEAD    AXD    AXATO:iriCAL    XECK.      219 

from  the  joint.  The  cases  reported  to  me  by  Dr.  Brainard,  and  al- 
ready described,  illustrate  this  latter  class. 

At  other  times  the  upper  fragment  turns  upon  its  own  axis,  and  is 
found  more  or  less  tilted  or  completely  rotated  in  the  socket ;  so  that 
its  cartilaginous  or  articulating  surface  rests  upon  the  broken  surface 
of  the  lower  fragment,  and  its  own  broken  surface  presents  toward 
the  glenoid  cavity. 

Eobert  Smith  has  described  a  specimen  of  this  kind,  which  he  re- 
moved from  the  body  of  a  woman,  aged  forty,  who  many  years  pre- 
vious to  her  death  fell  down  a  flight  of  stairs,  and  struck  her  shoulder 
with  great  violence  against  the  edge  of  one  of  the  steps.  Whether 
she  applied  to  a  surgeon  or  not  at  the  time  of  the  accident,  Mr.  Smith 
was  not  able  to  ascertain.  After  death  the  shoulder  looked  somewhat 
as  if  there  was  a  dislocation  of  the  humerus  into  the  axilla,  there  being 
a  marked  depression  under  the  acromion,  but  the  shaft  of  the  humerus 
was  drawn  upwards  and  inwards  toward  the  coracoid  process. 

When  the  capsular  ligament  was  opened,  the  head  of  the  bone  was 
found  to  have  been  broken  from  the  shaft  through  the  line  of  the  ana- 
tomical neck,  and  to  have  completely  turned  upon  itself;  and  the 
cartilaginous  surface  was  actually  driyen  one  inch  into  the  cancellated 
structure  of  the  shaft,  so  as  to  split  off  the  lesser  tubercle  with  a  portion 
of  the  greater.  Only  one-half  of  the  upper  fragment  was  thus  impact- 
ed, the  other  half  projecting  beyond  the  margin  of  the  lower  fragment. 
Between  the  cartilaginous  surface  and  the  shaft  no  union  had  occurred ; 
but  there  was  complete  bony  union  between  the  upper  and  lower 
fragment,  beyond  the  limits  of  the  cartilage. 

The  upper  surface  of  the  superior  fragment  rested  in  part  against 
the  inner  half  of  the  glenoid  cavity  and  upon  its  inner  margin,  and  in 
part  it  rested  against  the  neck  of  the  scapula  in  the  direction  of  the 
coracoid  process.^ 

Xelaton  saw  a  similar  specimen  in  the  possession  of  M.  Dubled,  the 
revolution  of  the  upper  fragment  being  complete;  but  there  was  no 
lateral  displacement,  and  the  union  had  been  accomplished  in  a  manner 
similar  to  that  which  is  seen  after  intra-capsular,  impacted  fractures, 
without  reversion.^ 

I  have  also  been  permitted  to  examine  a  specimen  belonging  to  Dr. 
Charles  A.  Pope,  of  St.  Louis,  Mo.,  which  seems  to  have  been  broken 
not  only  through  the  line  of  the  anatomical  neck,  but  also  through 
the  surgical  neck.  Both  fragments  are  united  by  bone,  the  lower 
fragment  being  carried  in  the  direction  of  the  coracoid  process,  while 
the  upper  fragment  appears  to  be  reversed,  so  that  its  articular  sur- 
face is  directed  toward  the  shaft,  and  its  broken  surface  articulates 
with  the  glenoid  cavity.     The  history  of  this  specimen  is  unknown. 

It  is  possible,  we  think,  that  these  extraordinary  changes  of  position 
were  not  the  direct  result  of  the  accident  which  broke  the  bone,  but 
that  they  had  been  taking  place  gradually  and  through  a  long  period. 
It  is  certainly  quite  as  probable  that  the  constant  motions  of  the  arm 

1  R.  Smith,  op.  cit.,  pp.  193-6. 

2  Nelaton,  Elemens  de  Pathol.  Chirur.,  torn.  prem.  p.  730. 


2:o 


FRACTURES    OF    THE    HUMERUS. 


M 


„\C 


) 


I''ig-  55.  Fig.  56.         should    accomplish    these    displace- 

ments, as  that  they  should  be  pro- 
duced by  a  direct  blow;  indeed,  the 
former  supposition  appears  to  us 
much  the  most  probable. 

Tliere  is  another  supposition  which, 
in  my  opinion,  is  capable  of  explain- 
ing most  of  the  phenomena  usually 
present  in  these  cases,  and  which,  if 
admitted,  renders  the  supposition  of 
a  fracture  unnecessary.  It  is,  that 
these  are  all  of  them  examples  of 
softening  of  the  neck  of  the  bone,  as 
a  result  of  chronic  inflammation,  ul- 
ceration, &c.;  and  that  the  changed 
position  of  the  head  is  due  to  pres- 
sure alone,  being  acted  upon  by  the 
muscles  which  surround  the  joint, 
and  which  act  all  the  more  vigor- 
ously because  they  partake  also  of 
the  inflammation  which  has  invaded 
the  bone.  This  view  of  these  speci- 
mens, which  had  already  more  than 
once  suggested  itself  to  me,  was  very 
strongly  confirmed  by  its  having 
occupied  the  mind  also  of  Dr.  Neill, 
of  Philadelphia,  and  who  at  his  own 
instance  stated  to  me  that  he  believed 
this  was  their  true  explanation.  We 
were,  at  the  time,  examining  Dr. 
Pope's  specimen,  already  alluded  to, 
and  on  comparing  it  with  a  specimen  of  dislocation  and  partial  absorp- 
tion of  the  head  of  the  humerus,  contained  in  Dr.  Neill's  Museum,  the 
points  of  resemblance  were  so  numerous  and  striking  that  we  felt 
compelled  to  doubt  whether  Dr.  Pope's  specimen,  together  with  those 
seen  by  Smith  and  Nelaton,  did  not  belong  to  the  same  class  with  this 
of  Neill's. 

In  a  case  of  fracture  of  the  "cervix  humeri  within  the  capsular  liga- 
ment," examined  by  Sir  Astley  Cooper,  there  was  also  a  complete 
forward  luxation  of  the  head ;  but  ligamentous  union  had  occurred 
between  the  fragments.'  Many  similar  cases  have  been  reported  by 
other  surgeons. 


Dr.  Pope's  Specimen. 
Front  view.  Side  view. 


§  2.  Fractures  THROUGH  THE  Tubercles.   {Extra-capsular ;  Non-impacted 

and  Impacted.) 

Under  this  division  we  intend  to  speak  of  all  fractures  traversing 
the  upper  end  of  the  humerus,  and  involving  the  tubercles,  or  of  all 


A.  Cooper  on  Dirflocations.,  &t;.,  p.  372. 


LONGITUDINAL    FRACTURES    OF    THE    HEAD    AND    NECK.     221 

those  which  occur  between  the  anatomical  neck  on  the  one  hand,  and 
the  epiphyseal  junction,  or  surgical  neck,  on  the  other  hand,  and  which 
may  be  more  or  less  oblique  as  well  as  transverse.  Fractures  of  the 
greater  or  lesser  tubercles  are  of  course  excepted,  since  they  are  more 
properly  longitudinal  fractures,  and  do  not  completely  traverse  the 
diameter  of  the  bone.  Nor  do  we  intend  to  include  those  fractures 
which  occur  at  the  epiphyseal  junction,  since,  being  below  the  princi- 
pal insertion  of  those  muscles  which  are  attached  to  the  tubercles,  they 
present  very  peculiar  and  distinctive  features  which  will  demand  for 
them  a  separate  classification. 

Cmcses,  Pathology,  and  Results. — Fractures  through  the  tubercles, 
like  fractures  through  the  anatomical  neck,  are  the  results  generally 
of  direct  blows  received  upon  the  shoulder.  They  are  not  usually 
accoHlpanied  with  much  lateral  displacement  at  the  point  of  fracture; 
a  circumstance  which  finds  a  partial  explanation  in  the  fact  that  the 
line  of  fracture  is  through  the  insertions  of  the  muscles  converging 
upon  the  tubercles  and  not  entirely  above  or  below  them,  so  that  they 
continue  to  act  nearly  equally  upon  both  fragments  ;  but  it  is  also 
sometimes  due  in  a  measure  to  impaction  :  the  head  being  forced  down- 
wards toward  the  axilla,  and  upon  the  shaft  until  it  is  made  to  ride 
npon  its  inner  or  axillary  wall  like  a  cap;  the  compact  bony  tissue 
of  the  shaft  penetrating  the  reticular  structure  of  the  head.  These 
fractures  generally  unite  by  bone;  yet  more  or  less  impairment  of  the 
motions  of  the  limb  results  from  the  inflammation  which  occurs  in  and 
about  the  joint,  or  from  the  irregular  deposits  of  callus  in  the  vicinity 
of  the  fracture. 


§  3.  Longitudinal  Fractures  of  the  Head  and  Neck  ;  or  Splitting  off 
OF  THE  Greater  Tubercle. 

Causes,  Pathology,  Symptoms,  and  Results. — Mr,  Guthrie  seems  to 
have  been  the  first  to  call  attention  to  this  peculiar  injury  of  the 
shoulder.  In  a  lecture  delivered  in  November,  1833,  he  described 
four  cases  which  had  come  under  his  observation,  and  which  he  re- 
garded as  examples  of  separation  of  the  small  tuberosity,  accompanied 
with  more  or  less  of  the  head,  the  fracture  extending  along  a  portion 
of  the  bicipital  groove,^ 

Robert  Smith,  however,  believes  that  it  was  the  greater  and  not  the 
lesser  tuberosity  which  was  thus  detached  in  the  cases  mentioired  b_y 
Mr,  Guthrie,  since  the  external  signs  were  so  nearly  like  those  which 
were  present  in  a  woman  seen  by  himself,  and  in  whom  an  autopsy 
enabled  him  to  verify  his  diagnosis.  The  following  is  the  case  as 
related  by  Mr,  Smith: — 

"  In  July,  1844, 1  was  requested  to  examine  the  body  of  Julia  Darby, 
fet.  80,  who  had  died  of  chronic  pulmonary  disease.  Upon  entering 
the  room,  the  appearances  of  the  left  shoulder-joint  at  once  attracted 
my  attention,  and  struck  me  as  being  different  from  those  which  attend 
the  more  common  injuries  of  this  articulation, 

'  Robert  Smith,  p.  ISl,  from  London  Med.  and  Phys.  Journal. 


222  FRACTURES    OF    THE    HUMERUS. 

"The  shoulder  had  lost,  to  a  certain  extent,  its  natural  rounded 
form;  the  acromion  process,  although  unusually  prominent,  did  not 
project  as  much  as  in  cases  of  dislocation  of  the  head  of  the  humerus. 
The  breadth  of  the  articulation  was  greatly  increased,  and  upon  press- 
ing beneath  the  acromion,  an  osseous  tumor  could  be  distinctly  felt, 
occupying  the  greater  part  of  the  glenoid  cavity ;  it  formed  a  promi- 
nence which  was  perceptible  through  the  soft  parts ;  it  moved  along 
with  the  shaft  of  the  humerus,  but  was  manifestly  not  the  head  of  the 
bone, 

"  A  second  and  larger  tumor,  presenting  the  rounded  form  of  the 
head  of  the  humerus,  lay  beneath  the  base  of,  and  internal  to,  the  cora- 
coid  process,  and  between  the  two  the  finger  could  be  sunk  into  a  deep 
sulcus,  placed  immediately  below  the  coracoid  process.  The  elbow 
could  be  brought  into  contact  with  the  side,  and  there  was  no  appre- 
ciable alteration  in  the  length  of  the  arm. 

"Upon  removing  the  soft  parts,  the  head  of  the  bone  presented  itself, 
lying  partly  beneath  and  partly  internal  to  the  coracoid  process.  The 
greater  tuberosity,  together  with  a  very  small  portion  of  the  outer 
part  of  the  head  of  the  bone,  had  been  completely  separated  from  the 
shaft  of  the  humerus.  This  portion  of  the  bone  occupied  the  glenoid 
cavity,  the  head  of  the  humerus  having  been  drawn  inwards  so  as  to 
project  upon  the  inner  side  of  the  coracoid  process;  it  was  still,  how- 
ever, contained  within  the  capsular  ligament. 

"  The  fracture  traversed  the  upper  part  of  the  bicipital  groove, 
which,  in  consequence  of  the  displacement  which  the  head  of  the  bone 
had  suffered,  was  situated  exactly  below  the  summit  of  the  coracoid 
process.  A  new  and  shallow  socket  had  been  formed  upon  the  costal 
surface  of  the  neck  of  the  scapula,  below  the  root  of  the  coracoid  pro- 
cess, and  the  inner  edge  of  the  glenoid  cavity  corresponded  to  the  pos- 
terior part  of  the  sulcus,  which  separated  the  head  of  the  bone  from 
the  detached  tuberosity.  The  latter  was  united  to  the  shaft  only  by 
ligament. 

"  The  capsule  had  not  been  injured,  but  was  thickened  and  en- 
larged, and  bone  had  been  deposited  in  its  tissue.  The  injury  had 
evidently  occurred  many  years  before  the  death  of  the  patient,  but 
the  history  connected  with  it  could  not  be  precisely  ascertained.'" 

Mr.  Smith  relates  one  other  case,  in  the  living  subject,  which  he 
saw,  in  connection  with  Mr.  Adams,  at  the  Richmond  Hospital,  and 
he  adds  that  "  numerous"  other  living  examples  have  fallen  under  his 
observation. 

Sir  Astley  Cooper  has  also  published  the  particulars  of  a  case  of 
fracture  of  the  greater  tubercle,  which  was  communicated  to  him  by 
Mr.  Herbert  Mayo.^ 

The  following  I  believe  also  to  have  been  an  example  of  this  rare 
accident:  — 

John  Hill,  set.  78,  fell  upon  the  side-walk,  striking  upon  his  right 
shoulder.     The  physician  to  whom  he  was  sent  thought  the  humerus 

'  Robert  Smith,  op.  cit.,  p.  178. 

^  A.  Cooper,  on  Dislocations  and  Fractures  of  the  Joints.  Edited  by  B.  Cooper. 
American  edition,  p.  384. 


FEACTUEES  THEOUGH  THE  SUEGICAL  NECK. 


223 


was  dislocated,  and  directed  him  to  the  Buffalo  Hospital  of  the  Sisters 
of  Charity,  but  he  did  not  apply  for  admission  until  eight  days  after, 
Oct.  14,  1857,  when  Dr.  Boardman  and  myself  examined  the  limb 
carefully. 

Although  we  placed  him  under  the  influence  of  chloroform,  the 
diagnosis  was  not  satisfactorily  made  out.  We  inclined,  however,  to 
the  opinion  that  it  was  a  fracture  of  the  greater  tubercle.  The  antero- 
posterior diameter  of  the  upper  end  of  tlie  bone  was  greatly  increased  ; 
there  was  occasional  distinct  crepitus,  but  the  limb  was  not  shortened. 

Subsequently,  the  examinations  were  repeated  many  times,  and  the 
depression  between  the  fragments  becoming  more  palpable,  the  diag- 
nosis was  at  length  confirmed. 

No  treatment  was  adopted,  except  confinement  in  bed,  and  stimulat- 
ing embrocations.  Two  months  after  the  accident  he  still  remained 
an  inmate  of  the  hospital,  his  shoulder  being  quite  stiff",  and  the  pro- 
jection continuing  in  front. 

Mr.  Eobert  Smith  thinks  that  when  the  displacement  is  considerable, 
the  fragments  generally  unite  by  ligament  rather  than  by  bone. 


§  4.  Fractures  through  the  Surgical  Neck.     {Including  Separations  at 
the  Upper  Epiphysis.) 

I  have  already  defined  the  "  Surgical  Neck"  as  all   of  that  narrow 
portion  commencing  at  the  epiphysis  and  terminating  at  the  insertion 
of  the  pectoralis  major  and  latissimus  dorsi.     It  seems 
proper,    therefore,   that  we  should  include  under  this         Fig-  57. 
division,  both  fractures  and  separations  occurring  at  the 
epiphysis,   especially  since,  owing  to  their  anatomical 
relations,  they  are  subject  to  the  same  displacements  as 
fractures  occurring  half  an  inch  or  one  inch  lower  down. 
The  capsular  muscles,  with  the  exception  of  the  teres  ff 

minor,  having  no  more  influence  over  the  lower  frag- 
ment when  a  separation  occurs  at  the  epiphysis,  than  i  ;| « 
when  a  separation  occurs  at    any  other   point  of  the 
surgical  neck. 

The  following  is  an  account  of  the  only  case  of  sepa- 
ration at  the  epiphysis  which  I  have  ever  recognized : — 

Mike  Bovin,  set.  13  months,  fell  sideways  from  his 
cradle  in  November,  1855.  He  was  taken  to  an  empiric, 
who  called  it  a  sprain,  and  applied  liniments.  Three 
weeks  after  the  accident  he  was  brought  to  me,  and  I 
found  the  arm  banging  beside  the  body,  with  little  or 
no  power,  on  the  part  of  the  child,  to  move  it.  There 
was  a  slight  depression  below  the  acromion  process,  and 
considerable  tenderness  about  the  joint ;  but  the  shoulder 
was  not  swollen,  nor  had  it  been  at  any  time.  The  line 
of  the  axis  of  the  bone,  as  it  hung  by  the  side,  was  di- 
rected a  little  in  front  of  the  socket. 

On  moving  the  elbow  backwards  and  forwards,  the  upper  end  of  the 


/ 


Separation     of 
upper   epiphysis. 


224  FRACTURES    OF    THE    HUMERUS. 

shaft  moved  in  the  opposite  directions  with  great  freedom,  and  could 
be  distinctly  felt  under  the  skin  and  muscles.  This  motion  was  ac- 
companied with  a  slight  sound,  or  sensation,  a  sensation  not  like  the 
grating  of  broken  bone,  but  much  less  rough.  There  was  no  short- 
ening of  the  limb.  When  the  elbow  was  carried  a  little  forwards  upon 
the  chest  the  fragments  seemed  to  be  restored  to  complete  coaptation ; 
and  of  this  I  judged  by  the  restoration  of  the  line  of  the  axis  of  the 
shaft  to  the  centre  of  the  socket,  and  by  the  complete  disappearance 
of  the  depression  under  the  point  of  the  acromion  process. 

I  applied  suitable  dressings  to  retain  the  arm  in  this  position ;  but 
five  months  after  the  injury  was  received  the  fragments  had  not  united, 
and  the  child  was  still  unable  to  lift  the  arm,  although  the  forearm 
and  hand  retained  their  usual  strength  and  freedom  of  motion.  The 
same  crepitus  could  occasionally  be  felt  in  the  shoulder,  and  the  same 
preternatural  mobility.  The  shoulder  was  at  this  time  neither  swollen 
nor  tender. 

Eobert  Smith  and  Sir  Astley  Cooper  both  speak  of  it  as  a  frequent 
accident  in  early  life,  but  the  recorded  cases  are  very  few.  The  case 
mentioned  by  Mr.  Smith  has  been  given  very  much  at  length,  and,  as 
a  characteristic  example,  deserves  to  be  repeated : — ■ 

"  During  the  early  part  of  last  year,  a  boy,  eight  years  of  age,  was 
admitted  to  the  Richmond  Hospital,  under  the  care  of  Dr.  McDowell. 
About  a  week  previous  to  his  admission  he  had  fallen  upon  the  shoul- 
der, and  at  once  lost  the  power  of  using  his  arm. 

"  It  was  at  first  sight  evident  that  there  did  not  exist  any  luxation 
of  the  head  of  the  humerus,  and  it  was  equally  obvious  that  the  case 
was  not  an  example  of  any  of  the  ordinary  fractures  to  which  the  neck 
of  the  bone  is  liable.  There  was  no  diminution  of  the  natural  rotundity 
of  the  shoulder,  nor  any  unusual  prominence  of  the  acromion  process; 
the  head  of  the  bone  could  be  distinctly  felt  in  the  glenoid  cavity,  and 
it  remained  motionless  when  the  arm  was  rotated;  there  was  very  little 
separation  of  the  elbow  from  the  side,  but  it  was  directed  slightly 
backwards. 

"About  three-quarters  of  an  inch  below  the  coracoid  process  there 
existed  a  remarkable  and  abrupt  projection,  manifestly  formed  by  the 
upper  extremity  of  the  shaft  of  the  humerus,  every  motion  imparted 
to  which  it  followed.  Its  superior  surface,  which  could  be  distinctly 
felt,  was  slightly  convex,  and  its  margin  had  nothing  of  the  sharpness 
which  the  edge  of  a  recently  broken  bone  presents  in  ordinary  fractures. 

"When  this  projecting  portion  of  the  bone  was  pushed  outwards,  so 
as  to  bring  it  in  contact  with  the  under  surface  of  the  head  of  the  hu- 
merus (previously  fixed  as  far  as  it  was  possible  to  do  so),  a  crepitus 
was  produced  by  rotating  a  shaft  of  the  bone.  It  did  not,  however, 
resemble  the  ordinary  crepitus  of  fracture,  but  it  would  be  extremely 
difficult,  by  any  description,  to  convey  a  clear  idea  of  what  the  differ- 
ence consisted  in, 

"  from  a  careful  consideration  of  the  symptoms  and  appearances 
above  mentioned  (taking  into  account  also  the  age  of  the  patient),  the 
diagnosis  was  formed,  that  the  injury  consisted  in  a  separation  of  the 
superior  epiphysis  of  the  humerus  from  the  shaft  of  the  bone.   Various 


FEACTUEES    THEOUGH    THE    SUEGICAL    NECK.  225 

mechanical  contrivances  were  employed  in  this  case,  but  all  proved 
ineffectual  in  maintaining  the  fragments  in  their  proper  relative  posi- 
tion.'" 

Sir  Astley  Cooper  has  also  briefly  described  one  example. 

"  Its  age  was  ten  years.  The  symptoms  of  the  injury  were,  inability 
of  moving  the  elbow  from  the  side,  or  of  supporting  the  arm,  unless 
by  the  aid  of  the  other  hand,  without  great  pain.  The  tension  which 
succeeded  filled  up  the  hollow  which  was  at  first  produced  by  the  fall 
of  the  deltoid  muscle.  When  the  head  of  the  bone  was  fixed,  the 
fractured  extremity  of  the  humerus  could  be  tilted  under  the  deltoid 
muscle,  so  as  to  be  felt,  and  even  shown,  by  raising  the  arm  at  the 
elbow.  Crepitus  could  be  perceived,  not  by  rotating  the  arm,  but  by 
raising  the  bone  and  pushing  it  outward.  The  cause  of  the  fracture 
was  a  fall  upon  the  shoulder  into  a  saw-pit  of  the  depth  of  eight  feet."^ 

It  will  be  necessary,  in  order  to  a  full  understanding  of  the  various 
aspects  of  this  fracture,  to  relate  several  illustrative  examples. 

Case  1.  Simple  fracture ;  never  displaced.  Union  without  deformity. — 
Alexander  Balentine,  set.  62 ;  admitted  to  the  Buffalo  Hospital  of  the 
Sisters  of  Charity,  December  19,  1851.  He  had  fallen  upon  the  side- 
walk, striking  upon  his  right  arm.  Dr.  Johnson,  of  Buffalo,  had  re- 
duced the  fracture  and  applied  appropriate  dressings.  No  union  of 
the  fragments  had  yet  occurred ;  but  as  the  surfaces  were  in  apposition, 
it  was  only  after  considerable  manipulation,  and  not  until  we  bent  the 
forearm  upon  the  arm,  and  rotated  the  humerus  by  means  of  the  fore- 
arm, that  the  crepitus  became  distinct,  and  gave  unequivocal  evidence 
of  the  existence  of  a  fracture,  and  of  its  situation. 

The  treatment,  after  admission,  consisted  in  the  application  of  one 
gutta  percha  splint,  accurately  moulded,  and  extending  from  above  the 
shoulder  to  below  the  elbow,  and  encircling  one-half  the  circumference 
of  the  arm  ;  the  splint  being  secured  with  the  usual  bandages,  &c. 

The  result  is  a  perfect  limb. 

Case  2.  Simple  fracture.  Union  ivith  displacement  and  deformity. — 
White,  of  Buffalo,  set.  12,  fell  fourteen  feet,  striking  on  the  front  and 
outside  of  the  left  shoulder.  Dr.  P.,  of  Erie  County,  saw  the  lad  within 
three  hours  (July  19, 1853).  He  was  brought  to  me  on  the  fourth  day 
after  the  accident.  The  upper  part  of  the  arm  was  then  very  much 
swollen.  I  found  the  arm  dressed  as  for  a  fracture  of  the  middle  or 
lower  third  of  the  humerus.  It  was  shortened  one  inch.  The  elbow 
was  inclined  backwards,  and  there  was  a  remarkable  projection  in  front 
of  the  joint,  feeling  like  the  head  of  the  bone.  The  hand  and  arm  were 
powerless.  I  suspected  a  dislocation  of  the  head  of  the  humerus  for- 
wards; and,  having  administered  chloroform,  I  attempted  its  reduction 
with  my  heel  in  the  axilla.  While  making  extension,  I  felt  a  sudden 
sensation  like  the  slipping  of  the  bone  into  its  socket,  but  on  examina- 
tion I  found  the  projection  continued  as  before.  I  then  repeated  the 
effort,  with  precisely  the  same  result. 

I  now  applied  an  arm  sling,  and  directed  leeches  and  cold  evapo- 
rating lotions. 

'  Robert  Smith,  op.  cit.,  p.  201.  ^  A.  Cooper,  op.  cit.,  p.  382. 

15 


226  FEACTUEES    OF    THE    HUMEEUS. 

On  the  25th,  five  days  after  the  accident,  it  was  examined  by  Drs. 
Mixer,  McGregor,  Joseph  Smith,  with  myself.  We  still  believed  it  was 
a  dislocation,  and  having  administered  chloroform,  we  again  attempted 
its  reduction.  The  same  slipping  sensation  was  produced  as  before, 
and  the  deformity  was  repeatedly  made  to  disappear;  but,  on  suspend- 
ing the  extension,  it  as  often  reappeared. 

The  character  of  the  accident  was  now  made  apparent,  and  we  pro- 
ceeded at  once  to  apply  the  splint  and  bandages  suitable  for  a  fracture 
of  the  surgical  neck  of  the  humerus,  namely,  a  gutta  percha  splint, 
extending,  on  the  outside,  from  the  top  of  the  shoulder  to  below  the 
elbow,  with  an  arm  and  body  roller  secured  with  flour  paste. 

On  the  81st,  twelve  days  after  the  accident,  Dr.  Wilcox,  Marine  Sur- 
geon at  Buffalo,  saw  the  arm  with  me.  The  fragments  were  displaced 
the  same  as  when  I  first  saw  it,  and  the  same  as  when  no  apparatus 
was  applied.  We  examined  it  again  carefully,  and  attempted  to  make 
the  fragments  remain  in  place,  but  we  were  unable  to  do  so,  except 
while  holding  them  and  making  extension. 

August  9  (twenty-first  day).  I  removed  all  the  dressings.  Motion 
between  the  fragments  had  ceased,  but  the  projection  and  shortening 
remained  as  before;  now,  also,  the  irregular  projections  of  the  fractured 
bones  were  more  distinctly  felt.  The  dressings  were  never  reapplied. 
Three  months  later  no  change  had  occurred.  He  could  carry  the  elbow 
forwards  freely,  as  well  as  backwards,  the  motions  of  the  shoulder-joint 
being  unimpaired. 

Case  3.  Sim-ple  fracture^  with  displacement;  resulting  in  deformity  and 
non-union. — L.  B.,  of  Lockport,  set.  43,  was  thrown  from  his  horse  in 
February,  1854,  striking  upon  his  right  elbow. 

Dr.  Maxwell,  an  experienced  surgeon  of  Lockport,  examined  and 
dressed  the  fracture.  Dr.  Fassett  was  present  and  assisted  at  a  subse- 
quent dressing.  Three  surgeons  who  examined  the  arm  before  Dr.  M., 
called  it  a  dislocation. 

Twelve  weeks  after  the  accident,  Mr.  B.  called  upon  me.  The  right 
arm  was  shortened  one  inch;  the  elbow  hung  off  slightly  from  the 
body  ;  the  upper  end  of  the  lower  fragment  was  distinctly  felt  in  front 
of  the  shoulder-joint  under  the  clavicle,  feeling  very  much  like  the 
head  of  the  bone.  The  fragments  were  not  united,  but  they  could  be 
seized  easily,  and  made  to  move  separately  and  freely.  He  stated  to 
me  that  he  was  subject  to  rheumatism,  and  especially  in  the  shoulder 
and  arm  of  the  side  injured.  He  wished  to  know  whether  it  could 
not  be  "re-set." 

Two  years  after,  I  found  the  bone  still  ununited.  He  was,  however, 
able  to  write  with  that  hand,  having  first  lifted  his  arm  with  the  other 
hand  and  laid  it  upon  the  table. 

Case  4.  Simple  fracture,  prohahly  impacted ;  resulting  in  deformity. — 
Wm.  A.,  of  Buffalo,  set.  15,  fell  backwards,  June  4,  1855,  striking  on 
his  back  and  left  shoulder.  Dr.  L.  saw  it  immediately,  and,  regarding 
it  as  a  dislocation,  attempted  its  reduction.  He  subsequently  repeated 
the  attempt.  I  saw  the  patient  with  Dr.  L,  on  the  tenth  day.  The 
arm  was  shortened  one  inch  and  a  half.  The  fragments  were  displaced 
forwards,  projecting  in  front  of  and  a  little  below  the  joint.     As  in 


FEACTURES  THROUGH  THE  SURGICAL  NECK.      227 

Case  3,  it  might  easily  be  mistaken  for  the  head  of  the  bone ;  but  the 
difficuitj  of  diagnosis  had  been  very  much  lessened  by  the  subsidence 
of  the  swelling.  There  was  no  motion  between  the  fragments;  nor 
could  the  deformity,  by  any  manipulation  or  extension,  be  made  to 
disappear.     It  was  probably  impacted. 

March  23,  1856,  nearly  ten  months  after  the  accident,  I  found  the 
fragments  remaining  as  when  I  first  examined  the  limb,  and  the  arm 
shortened  one  inch  and  a  half.  The  elbow  hung  a  very  little  back 
from  the  line  of  the  body.  The  upper  end  of  the  lower  fragment  was 
lifted  to  within  one  inch  of  the  head  of  the  humerus ;  the  upper  frag- 
ment having  its  head  in  the  socket,  with  its  lower  end  downwards  and 
forwards.  The  arm  was,  however,  in  every  respect  as  useful  as  before 
it  was  broken.  It  was  equally  strong,  and  he  could  raise  his  arm  as 
high,  and  move  it  in  every  direction  as  freely,  as  he  could  the  other. 

Causes. — Epiphj'-seal  separations  belong  almost  exclusively  to  child- 
ren, but  true  fractures  at  the  surgical  neck  occur  most  often  in  adult 
life;  with  the  exception  of  the  two  lads,  one  of  whom  was  twelve 
years  old,  and  the  other  fifteen,  all  of  the  examples  of  this  latter  acci- 
dent seen  by  me  occurred  in  adults,  and  of  twenty  cases  in  which  I 
find  the  ages  recorded,  the  average  age  is  forty -three  years;  yet  Sir  A. 
Cooper  declares  these  fractures  to  be  most  common  in  infancy,  while 
Malgaigne  has  never  seen  a  case  in  a  person  under  fifty-three  years. 

Both  epiphyseal  separations  and  fractures  at  this  point  are  occa- 
sioned, in  most  cases,  by  direct  blows  or  falls  upon  the  shoulder.  Of 
nineteen  examples  in  which  I  find  the  cause  recorded,  fourteen  were 
from  dii'ect  blows,  four  from  indirect  blows,  and  one  from  muscular 
action,  as  in  throwing  a  ball.  Of  the  four  resulting  from  indirect 
blows,  one  was  from  a  fall  upon  the  hand,  seen  by  Desault,  and  three 
were  from  falls  upon  the  elbow,  of  which  two  were  seen  by  Desault, 
a)]d  one  (Case  4)  by  myself. 

Pathology. — I  have  found  the  fragments  sensibly  displaced  in  five 
cases  out  of  seven;  a  proportion  much  greater  than  has  been  observed 
by  Malgaigne,  who  has  only  seen  a  displacement  twice  in  more  than 
twenty  cases.  It  is  certain,  however,  that  complete  or  sensible  dis- 
placement is  less  common  in  this  fracture  than  in  most  other  fractures, 
the  broken  ends  being  retained  in  place,  probably,  by  the  long  tendon 
of  the  biceps. 

As  to  the  direction  of  the  displacement,  I  have  seen  the  upper  end 
of  the  lower  fragment  drawn  forwards  and  upwards  toward  the  cora- 
coid  process  three  times,  in  one  of  which  examples  the  upper  fragment 
plainly  followed  in  the  same  direction.  Sir  Astley  Cooper  declares 
that  with  infants  this  direction  is  constant,  and  in  museum  specimens 
I  have  seen  but  one  exception.  In  the  specimen  of  fracture  of  the 
surgical  neck,  with  also  displacement  of  the  head,  belonging  to  Dr. 
Pope,  this  direction  of  the  fragments  is  plainly  seen,  as  also  in  a  spe- 
cimen belonging  to  Dr.  Neil),  of  the  Pennsylvania  Medical  College, 
where  the  lower  fragment  almost  reaches  the  coracoid  process,  and  in 
a  specimen  contained  in  one  of  the  cabinets  of  the  University  of 
Pennsylvania,  where  the  upper  end  of  the  lower  fragment  has  become 
united  by  bone  to  the  coracoid  process. 


228  FRACTURES    OF    THE    HUMERUS. 

The  only  exception  which  I  have  met  with  is  in  the  possession  of 
Dr.  Neill.  In  this  example  the  two  ends  are  tilted  toward  the  axilla. 
In  the  recorded  examples,  also,  I  find  the  displacement  forwards  men- 
tioned four  times,  and  the  displacement  toward  the  axilla  but  once.  I 
am  compelled,  therefore,  to  doubt  the  accuracy  of  Malgaigne's  obser- 
vations, who  thinks  he  has  seen  the  lower  fragment  most  often  drawn 
toward  the  axilla,  as  well  as  the  observations  of  those  who  think  that 
the  upper  fragment  is  generally  displaced  outwards;  yet,  no  doubt, 
they  do  sometimes  assume  this  position.  Desault  has  seen  them  both 
thrown  backwards ;  while  Dupuytren,  Paletta,  and  others  have  seen 
them  pushed  outwards ;  and  I  have  in  my  cabinet  the  copy  of  a  speci- 
men in  which  both  fragments  are  drawn  outwards,  but  the  lower  frag- 
ment is  to  the  inner  side  of  the  upper. 

When  the  fractui-e  occurs  at  or  near  the  epiphysis,  it  is  sometimes 
accompanied  with  impaction,  of  the  same  character  as  we  have  already 
described  when  speaking  of  fractures  through  the  tubercles.  Robert 
Smith  has  given,  in  his  treatise,  an  engraving  intended  to  illustrate 
he  relative  position  of  the  fragments  in  extra-capsular  impacted  frac- 
tures, and  the  line  of  separation  very  nearly  corresponds  to  the  line  of 
junction  of  the  epiphysis  with  the  shaft. 

But  in  a  majority  of  cases  no  impaction  occurs.  Dr.  Charles  A. 
Pope,  of  St,  Louis,  Mo.,  has  two  specimens  of  this  kind,  in  which  no 
union  has  taken  place,  nor  is  there  any  evidence  that  impaction  had 
ever  occurred.  In  one  case  the  line  of  fracture  commences  at  the 
junction  of  the  head  with  the  shaft,  and  extends  thence  irregularly 
across  to  a  point  half  an  inch  below  the  greater  tuberosity.  In  the 
second  specimen  the  fracture  commences  at  the  same  point  and  ter- 
minates three-quarters  of  an  inch  below  the  greater  tuberosity.  In 
relation  to  these  bones.  Dr.  Pope  remarks :  "  These  are  not  cases  of 
detachment  of  the  epiphyses,  as  the  bones  are  evidently  those  of  adults, 
and  there  is,  at  their  lower  extremities  above  the  condyles,  no  trace  of 
an  epiphyseal  line." 

Results. — Four  of  the  examples  of  fracture  of  the  surgical  neck  seen 
by  me  resulted  in  perfect  limbs,  and  three  are  more  or  less  deformed ; 
but  it  has  already  been  noticed  that  of  the  whole  number  only  five 
were  ever  displaced,  and  of  these  five,  only  two  are  completely  re- 
stored. In  one  of  these  no  bony  union  has  taken  place  after  the  lapse 
of  two  years  or  more.  It  is  satisfactory,  however,  to  know  that,  with 
the  exception  of  this  last  (Case  3),  all  of  the  patients  have  recovered 
the  free  and  complete  use  of  their  arms. 

jSym2:)toms,  or  Differential  Diagnosis  of  Accidents  about  the  Shoulder- 
joint. — No  place  could  be  more  appropriate  than  this  to  call  attention 
to  the  diflQculty  of  diagnosis  in  the  case  of  accidents  about  the  shoul- 
der-joint, a  difficulty  which  surgeons  have  constantly  recognized,  and 
which  has  sometimes  rendered  diagnosis  impossible. 

In  presenting  an  epitome  of  the  prominent  diagnostic  signs,  I  would 
refer  the  reader  who  seeks  further  information  to  my  report  to  the 
American  Medical  Association,  where  the  subject  is  treated  more 
elaborately  than  is  consistent  with  the  design  of  the  present  volume. 


DIFFERENTIAL    DIAGNOSIS    OF    ACCIDENTS.  229 

Let  US  first  study  the  ordinary  signs  of  a  dislocation  at  the  shoulder- 
joint,  regarding  this  as  the  type  with  which  the  other  accidents  are  to 
be  compared. 

a.  Signs  of  a  Dislocation.  [Cause,  generally  a  fall  upon  the  elbow  or 
hand.) 

1.  Preternatural  immobility. 

2.  Absence  of  crepitus. 

3.  When  the  bone  is  brought  to  its  place  it  will  remain  without  the 
employment  of  force. 

These  three  are  common  signs,  which  apply  to  any  other  joint  as 
well  as  the  shoulder. 

4.  Inability  to  place  the  hand  upon  the  opposite  shoulder,  or  to 
have  it  placed  there  by  an  assistant,  while  at  the  same  time  the  elbow 
touches  the  breast.  This  is  a  sign  common  to  all  of  the  dislocations 
of  the  shoulder.^ 

The  following  are  special  signs,  or  such  as  belong  only  to  particular 
dislocations  of  the  shoulder. 

5.  Depression  under  the  acromion  process ;  always  greatest  under- 
neath the  outer  extremity,  but  more  or  less  in  front  or  behind,  accord- 
ing as  the  dislocation  may  be  into  the  axilla,  forwards  or  backwards. 

6.  Round,  smooth  head  of  the  bone  felt  in  its  new  situation,  and 
very  probably  removed  from  its  socket ;  moving  with  the  shaft.  Ab- 
sence of  the  head  of  the  bone  from  the  socket. 

7.  Elbow  carried  outwards,  and  in  certain  cases  forwards  or  back- 
wards, and  not  easily  pressed  to  the  side  of  the  body. 

8.  Arm  shortened  in  the  dislocation  forwards,  and  slightly  length- 
ened when  in  the  axilla. 

b.  Signs  of  a  Fracture  of  the  Neck  of  the  Scapula.  [Cause,  generally 
a  direct  blow.) 

1.  Preternatural  mobility. 

2.  Crepitus,  generally  detected  by  placing  the  finger  on  the  coracoid 
process  and  the  opposite  hand  upon  the  back  of  the  scapula,  while  the 
head  of  the  humerus  is  pushed  outwards  and  rotated. 

3.  When  reduced  it  will  not  remain  in  place. 

4.  The  hand  may  generally,  but  with  difficulty,  be  placed  upon  the 
opposite  shoulder. 

5.  Depression  under  the  acromion  process,  but  not  so  marked  as  in 
dislocation. 

6.  Head  of  the  bone  may  be  felt  in  the  axilla,  but  less  distinctly  than 
in  dislocation.  Never  much  forwards  or  backwards.  Head  of  the  bone 
moves  with  the  shaft.  Head  of  the  bone  not  to  be  felt  under  the  acro- 
mion process,  although  it  has  not  left  its  socket. 

7.  Elbow  carried  a  little  outwards,  but  not  so  much  as  in  dislocation. 
Easily  brought  against  the  side  of  the  body. 

8.  Arm  lengthened. 

9.  The  coracoid  process  carried  a  little  toward  the  sternum,  and 
downwards. 

1  Report  on  a  New  Principle  of  Diagnosis  in  Dislocations  of  the  Shoulder-joint,  by 
L.  A.  Diigas,  Prof,  of  Surgery  in  the  Medical  College  of  Georgia.  Trans.  Amer.  Med. 
Assoc,  vol.  X.  p.  175. 


230  FUACTUEES    OF    THE    HUMEEUS. 

10.  Pressing  upon  tlie  coracoid  process  it  is  found  to  be  movable, 
and  it  is  also  observed  that  it  obeys  the  motions  of  the  arm. 

c.  Signs  of  Fracture  of  the  Anatomical  Neck  of  the  Humerus.  Intra- 
capsular. {Cause,  a  direct  blow;  generally  opening  to  the  joint,  but 
not  always.) 

1.  Mobility  not  increased,  nor  diminished. 

2.  Crepitus,  generally  discovered  by  pressing  up  the  head  of  the 
bone  into  its  socket  and  rotating;  or,  when  the  tubercles  are  also  broken, 
by  grasping  the  tubercles  and  rotating  the  arm. 

8.  Fragments  not  generally  displaced. 

4.  The  hand  can  be  placed  easily  upon  the  opposite  shoulder. 

5.  Yery  slight,  if  any,  depression  under  the  acromion  process. 

6.  Head  of  the  bone  generally  in  its  socket,  but  not  felt  so  distinctly 
as  before  the  fracture. 

7.  Elbow  falls  easily  against  the  side  of  the  body,  or  is  easily  placed 
there. 

8.  Arm  not  lengthened,  nor  appreciably  shortened,  unless  the  head 
be  driven  so  much  into  the  body  as  to  separate  the  tubercles. 

9.  In  this  latter  case  there  are  present  also  the  signs  of  fracture  of 
the  tubercles, 

d.  Signs  of  Fracture  of  the  Humerus  through  the  Tubercles.  Extra- 
capsular.    {Cause,  direct  blows.) 

1.  Generally,  there  is  neither  marked  mobility  nor  immobility,  ex- 
cept what  immobility  may  be  due  to  a  contusion  of  the  muscles. 

2.  (Crepitus,  discovered,  but  not  so  easily  as  in  intra-capsular  frac- 
tures, by  rotating  the  arm  while  the  tubercles  are  grasped  firmly. 

3.  If  displacement  exists,  the  fragments  are  not  always  easily  kept 
in  place  when  once  reduced. 

4.  The  hand  can  be  placed  upon  the  opposite  shoulder. 

5.  No  depression  under  the  acromion  process. 

6.  Head  of  the  bone  in  its  socket,  and  moving  with  the  shaft,  when, 
as  is  usually  the  case,  it  is  impacted. 

7.  Elbow  hangs  against  the  side  of  the  body. 

8.  Arm  shortened  when  impacted,  but  not  very  appreciably. 

The  signs  which  characterize  this  accident  are  more  obscure  than  in 
either  of  the  other  shoulder  accidents.  They  are  mostly  negative,  and 
will  not  generally  be  determined  positively  except  in  the  autopsy. 

e.  Signs  of  a  Longitudinal  Fracture  of  the  Head  and  Neck,  or  splitting 
off  of  the  Greater  Tubercle.  {Cause,  direct  blow  upon  the  front  of  the 
shoulder.) 

1.  Mobility  of  the  limb  natural. 

2.  Crepitus;  elicited  especially  by  grasping  the  tubercles  and  rotat- 
ing the  arm,  or  by  carrying  it  up  and  back  and  then  rotating. 

3.  When  reduced,  the  fragments  will  not  remain  in  place. 

4.  The  hand  can  be  placed  upon  the  opposite  shoulder. 

5.  Some  depression  under  the  acromion  process. 

6.  A  smooth  bony  projection  directly  underneath  the  coracoid  pro- 
cess, or  close  upon  its  inner  or  outer  side,  moving  with  the  shaft.  The 
head  of  the  bone  cannot  be  felt  in  the  socket,  yet  the  space  under  the 
acromion  is  not  entirely  unoccupied. 


DIFFEEENTIAL    DIAGNOSIS    OF    ACCIDENTS.  231 

7.  Generally,  but  not  always,  the  elbow  hangs  against  the  side. 
Sometimes  it  inclines  a  little  backwards.  It  can  always  be  easily 
brought  to  the  side. 

5.  Arm  generally  neither  lengthened  nor  shortened. 

9.  A  remarkable  increase  in  the  antero-posterior  diameter  of  the 
upper  end  of  the  bone. 

10.  A  deep  vertical  sulcus  between  the  tubercles,  corresponding  with 
the  upper  part  of  the  bicipital  groove. 

f.  Signs  of  a  Fracture  through  the  Surgical  Nech.  {Cause,  direct  blows.) 

1.  Preternatural  mobility  often,  but  not  constantly  present. 

2.  Crepitus,  produced  easily  when  there  is  no  impaction,  or  when 
the  displacement  is  not  complete,  but  with  difficulty  when  impaction 
exists  or  the  displacement  is  complete. 

3.  When  once  the  fragments  have  been  displaced,  it  is  exceedingly 
difficult  ever  afterward  to  maintain  them  in  place. 

4.  If  the  fragments  remain  in  place,  the  hand  can  be  easily  placed 
upon  the  opposite  shoulder.  When  completely  overlapped  it  is  difii- 
cult. 

6.  A  slight  depression  below  the  acromion,  not  immediately  under- 
neath its  extremity,  but  an  inch  or  more  below. 

6.  Head  of  the  bone  in  the  socket,  and  moving  with  the  shaft  when 
impacted,  but  not  moving  with  the  shaft  when  not  impacted.  The 
upper  end  of  the  lower  fragment  being  often  felt  distinctly  pressing 
upwards  toward  the  coracoid  process ;  its  broken  extremity  being  easily 
distinguished  by  its  irregularity  from  the  head  of  the  bone. 

7.  Elbow  hanging  against  the  side  when  the  fragments  are  not  dis- 
placed, but  away  from  the  side  when  displacement  exists. 

8.  Length  of  arm  unchanged  unless  the  fragments  are  impacted  or 
overlapped  ;  or  both  fragments  are  much  tilted  inwards.  If  the  frag- 
ments are  completely  displaced,  the  arm  is  shortened. 

g.  Signs  of  a  Separation  at  the  Epiphysis.     {Cause,  direct  blows.) 

1.  Preternatural  mobility. 

2.  Feeble  crepitus;  less  rough  than  the  crepitus  produced  when 
broken  bones  are  rubbed  against  each  other. 

3.  Fragments  replaced  are  not  easily  maintained  in  place. 

4.  Same  as  in  preceding  variety  of  fracture. 

5.  The  depression  is  not  immediately  under  the  acromion,  yet  higher 
than  in  most  fractures  of  the  surgical  neck,  perhaps  three-quarters  of 
an  inch  below  the  acromion  process. 

6.  Head  of  the  bone  in  its  socket,  and  not  moving  with  the  shaft. 
Upper  end  of  lower  fragment  projecting  in  front,  when  displacement 
exists,  and  feeling  less  sharp  and  angular  than  in  case  of  a  broken 
bone ;  indeed,  being  slightly  convex  and  rather  smooth,  it  may  easily 
be  mistaken  for  the  head  of  the  bone. 

7.  Same  as  in  preceding  variety. 

8.  Length  of  arm  not  changed  unless  the  fragments  are  overlapped, 
or  both  fragments  are  tilted  upon  each  other.  When  the  fragments 
are  overlapped,  the  arm  is  shortened. 

9.  This  accident  is  almost  peculiar  to  infancy  and  childhood.  It 
seldom  occurs  after  the  fifteenth  year. 


232  FEACTUEES    OF    THE    HUMEEUS. 

There  are  other  accidents  about  the  shoulder-joint,  such  as  a  patho- 
logical partial  luxation  of  the  humerus,  dislocation  of  the  tendon  of 
the  biceps,  &c.,  which  might  possibly  be  confounded  with  fractures, 
but  the  consideration  of  which  I  shall  reserve  for  another  time. 

Treatmeyit. — I  have  already  spoken  of  the  treatment  of  fractures  of 
the  neck  of  the  scapula,  and  my  remarks  will  now  be  confined  to 
fractures  of  the  upper  end  of  the  humerus. 

Fractures  of  the  Anatomical  Neck ;  Intra-capsular. — As  has  already 
been  stated,  these  are  generally  compound  fractures,  and  from  the 
extent  of  the  injury  often  demand  amputation  of  the  entire  arm.  If 
an  effort  is  made  to  save  the  arm,  splints  will  not  be  applied,  and  the 
treatment  will  have  little  or  no  reference  to  the  existence  of  a  fracture; 
it  will  be  directed  only  to  the  reduction  or  prevention  of  the  inflam- 
mation, &G.  At  a  later  period  the  head  of  the  bone  may  escape  spon- 
taneously, or  it  may  become  necessary  to  remove  it  by  an  operation. 

Simple  fracture  of  the  anatomical  neck,  without  any  external  wound 
communicating  with  the  joint,  and  accompanied,  as  it  often  is,  with 
impaction,  frequently  unites,  or  the  upper  fragment  becomes  encased 
in  the  lower. 

It  is  not  proper  in  such  cases  to  employ  great  violence  for  the  pur- 
pose of  detecting  crepitus,  lest  the  fragments  should  become  displaced ; 
and  if  the  arm  should  be  found  to  be  a  little  shortened,  it  must  not  be 
extended,  with  a  view  to  overcoming  the  shortening,  since  upon  the 
impaction  probably  depends,  in  a  great  measure,  the  chances  of  union. 

The  elbow  and  forearm  may  be  suspended  in  a  sling,  while  the  arm 
is  gently  supported  against  the  side,  merely  to  insure  quietude.  No 
splitits  are  necessary  or  useful. 

Treatment  of  Fractures  through  the  Tubercles  [Extra-capsular) ;  Non- 
impacted  and  Impacted. — In  these  cases,  also,  the  fragments  being  seldom 
displaced,  very  little  if  any  mechanical  treatment  is  demanded.  A 
sling  is  all  that  is  usually  required.  If,  however,  on  account  of  dis- 
placement of  the  fragments,  a  splint  is  thought  necessary,  it  must  be 
applied  in  the  manner  hereafter  to  be  directed  in  cases  of  fractures  of 
the  surgical  neck. 

If  impaction,  with  shortening,  exists,  the  same  remarks  are  appli- 
cable here  as  in  intra-capsular  impacted  fractures,  namely,  that  we 
ought  not  to  rotate  the  limb  much,  nor  violently,  in  order  to  discover 
crepitus,  nor  make  extension  with  the  view  of  overcoming  the  short- 
ening, since  the  fragments  unite  more  promptly  and  certainly  when 
the  impaction  remains,  and  its  continuance  in  no  way  damages  the 
usefulness  of  the  limb. 

Treatment  of  Longitudinal  Fractures  of  the  Head  and  Neck,  or  of  a 
Separation  of  the  Greater  Tubercle, — In  the  only  instance  which  I  have 
recognized  as  a  fracture  of  the  greater  tubercle,  and  already  referred 
to,  the  displacement  was  moderate,  and  could  not  be  overcome,  either 
by  change  of  position  or  by  pressure  with  extension.  The  patient 
was  therefore  merely  laid  upon  his  back  in  bed.  No  dressings  of  any 
kind  were  employed,  and  the  fragments  seemed  to  unite  promptly, 
and  with  no  increase  in  the  displacement. 

If  the  displacement  is  originally  more  considerable,  attempts  ought 


FRACTUEES    THROUGH    THE    SURGICAL    XECK.  233 

still  to  be  made  to  reduce  the  fragments,  bj  extension  and  abduction 
of  the  arm,  with  direct  pressure;  yet  they  will  not  generally  prove 
completely  successful,  nor  will  it  be  found  easy  to  retain  them  when 
reduced. 

Mr.  Mayo  treated  a  fracture  of  this  character,  which  occurred  in  a 
man  sixty  years  of  age,  with  a  figure-of-8  bandage,  and  a  sling,  with 
a  lathe  splint  on  the  outer  side  of  the  humerus,  the  upper  part  of 
which  was  made  to  bear  on  the  fragments,  by  uniting  the  upper  part 
of  the  circular  arm  roller  to  the  figure-of-8  bandage.  "  The  fracture 
united  favorably,"  he  says,  but  we  presume  that  he  does  not  mean  to 
affirm  that  it  united  without  any  degree  of  displacement ;  a  result 
which,  probably,  ought  never  to  be  expected.  Mr.  Mayo  adds,  how- 
ever, that  "for  a  long  time  the  patient  had  some  difficulty  in  carrying 
the  arm  backward.'" 

Treatment  of  Fractures  of  the  Surgical  Xecl\  including  Sejjarations  at 
the  Epiphysis. — I  see  no  reason  to  suppose  that  the  indications  of  treat- 
ment can  essentially  vary  in  separations  at  the  epiphysis,  from  those 
in  true  fractures  through  any  part  of  the  surgical  neck,  since  the  rela- 
tive action  of  the  muscles  remains  the  same,  and  the  direction  of  the 
displacement  is  generally  the  same.  My  remarks,  therefore,  upon  this 
point  maybe  considered  as  equally  applicable  to  fractures  and  epiphy- 
sary  separations. 

In  a  considerable  proportion  of  these  cases  not  much  displacement 
of  either  fragment  takes  place,  and  consecjuently  we  have  only  to  apply 
such  moderate  retentive  means  as  will  insure  quiet.  Indeed,  under 
such  circumstances  we  might  not  hesitate  to  adopt  the  posture  treat- 
ment practised  by  Dupuytren  in  two  cases,  both  of  which  terminated 
favorably.  The  treatment  consisted  in  placing  the  arm,  semi-flexed, 
on  a  pillow,  the  pillow  being  arranged  so  as  to  form  a  pyramid,  the 
summit  of  which  was  lodged  in  the  axilla,  while  the  elbow  was  secured 
to  the  side  of  the  body  by  a  bandage.^ 

Unhappily,  however,  as  we  have  seen,  this  condition  is  not  always 
present ;  the  most  frequent  form  of  displacement  being  that  in  which 
the  lower  fragment  is  drawn  upwards  and  inwards,  or  toward  the 
coracoid  process. 

In  such  cases  it  will  require,  often,  no  little  perseverance  and  skill 
to  effect  reduction,  if  it  is  not  found  to  be  actually  impossible,  and 
still  more  to  retain  the  bones  in  place  when  once  reduced.  Indeed,  it 
is  proper  to  say  that  a  complete  reduction  is  seldom  accomplished  and 
permanently  maintained,  owing,  probably,  to  the  advantageous  action 
of  the  muscles  which  tend  to  produce  the  displacement,  and  in  part 
also  to  the  difficulty  of  applying  any  apparatus  or  dressing  which  shall 
act  efficiently  upon  the  fragments. 

Sir  Astley  Cooper  recommends  for  this  accident  a  couple  of  splints, 
to  be  placed  one  in  front  of  and  one  behind  the  shoulder,  an  axillary 
pad,  a  clavicular  bandage,  and  a  sling;  the  sling  being  made  to  suspend 
only  the  wrist  and  not  the  elbow,  since  he  had  observed  that  when  the 

'  B.  Cooper's  edition  of  Sir  A.  Cooper  on  Dislocations,  &c.,  American  edition,  p.  385. 
^  Dupuytren  on  Bones    Sydenham  edition,  p.  99. 


234 


FRACTURES    OF    THE    HUMERUS. 


elbow  was  lifted  the  upper  end  of  the  shaft  was  inclined  to  fall  for- 
wards. 

Mr.  Tyrrell  informed  Mr.  Cooper  that  in  a  similar  case  he  had  found 
the  bone  best  maintained  in  its  natural  position  by  its  being  raised 
and  supported  at  right  angles  with  the  side,  by  a  rectangular  splint,  a 
part  of  which  rested  against  the  side,  while  the  arm  reposed  upon  the 
other  part;  and  until  he  had  made  use  of  this  plan,  he  could  not 
succeed  in  removing  the  deformity,  or  in  keeping  the  bone  in  its 
place. 

Mr.  Erichsen  has  found  a  very  convenient  apparatus  to  consist  of 
"  a  leather  splint  about  two  feet  long  by  six  inches  broad,  bent  upon 
itself  in  the  middle,  so  that  one  half  of  it  may  be  applied  lengthwise 
to  the  chest,  and  the  other  half  to  the  inside  of  the  injured  arm,  the 
angle  formed  by  the  bend,  which  should  be  somewhat  obtuse,  being 
well  pressed  up  into  the  axilla," 

The  following  is  the  plan  which  I  would,  however,  generally  re- 
commend : — 

The  fragments  having  been  reduced  as  completely  as  possible,  a 
broad  and  firm  gutta-percha  splint  should  be  moulded  to  the  outside 
of  the  arm  and  shoulder.  When  it  has  become  sufficiently  hard  and 
firm,  it  may  be  secured  in  place  by  a  roller  carried  from  the  elbow  to 
the  axilla.  If  the  splint  covers  well  the  top  of  the  shoulder,  and  is 
sufficiently  wide,  it  is  not  apt  to  become  displaced;  and  by  resting 
against  the  point  of  the  acromion  process,  it  enables  the  upper  turns 
of  the  bandage  to  draw  the  broken  end  of  the  lower  fragment  outwards; 
at  least,  as  effectually  as  any  other  dressing  is  capable  of  doing,  and 
renders  an  axillary  pad  unnecessary.  The  sling  may 
then  be  applied  as  recommended  by  Sir  Astley  Cooper, 
or  the  arm  may  be  permitted  to  hang  perpendicularly 
beside  the  body.  The  clavicular  bandage  also  recom- 
mended by  Sir  Astley  complicates  the  dressing  very 
much,  and  does  not  seem  to  me  to  answer  any  useful 
purpose;  while  the  axillary  pad  exposes  the  brachial 
plexus  to  painful  if  not  injurious  pressure. 

As  a  substitute  for  gutta  percha,  a  firm  sheet  of  felt 
may  be  employed,  or  a  carved  wooden  splint,  or  the 
very  complete  shoulder  and  arm  splint  of  Welch,  but 
in  either  case  the  upper  portion  of  the  splint  ought 
always  to  rest  upon  the  shoulder,  so  as  to  prevent  its 
sliding  downwards. 

Dr.  Waters  read  before  the  ^sculapian  Society  of 
the  University  of  New  York,  a  remarkable  case  of 
compound  and  comminuted  fracture  of  the  shaft  and 
surgical  neck  of  the  humerus,  in  which  the  constant 
protrusion  of  the  upper  end  of  the  middle  fragment  in 
the  region  of  the  axilla  finally  rendered  resection  of 
the  head  and  neck  necessary.  This  operation  was  made  by  Dr.  Waters, 
on  the  eighteenth  day ;  and  four  months  after,  the  patient  was  so  far 
recovered  as  to  be  able  to  write  a  letter  with  the  limb  upon  which  the 


Welch's  shoulder 
splint. 


SHAFT  BELOW  THE  SURGICAL  NECK.        '  235 

operation  had  been  made.^  It  may  be  regarded,  therefore,  as  a  signal 
triumph  of  conservative  surgery,  since  the  alternative  presented  was 
only  between  amputation  and  resection.  In  a  similar  case,  Dr.  W.  H. 
Van  Buren,  of  Xew  York,  was  compelled  to  amputate  at  the  shoulder- 
joint,  after  which  the  patient  made  a  good  recovery,^ 


§  5.  Shaft,  below  the  Surgical  Neck  and  above  the  Base  of  the 

Condyles. 

GazLses. — In  a  record  of  seventeen  cases  in  which  the  cause  of  the 
fracture  is  stated,  I  find  this  portion  of  the  shaft  broken  from  direct 
blows  ten  times;  from  indirect  blows,  the  concussion  being  received 
upon  the  elbow,  twice  ;  once  it  was  a  consequence  of  tertiary  lues,  once 
it  occurred  during  birth,  and  three  times  in  the  same  patient  it  has 
been  broken  from  muscular  action  alone,  each  consecutive  fracture 
occurring  at  a  different  point.  The  records  of  surgery  furnish  many 
examples  of  fracture  of  the  shaft  of  the  humerus  from  muscular  action, 
as  in  throwing  a  stone,  or  a  snowball ;  but  the  most  singular  examples 
are  those  in  which  the  bone  has  been  broken  in  a  trial  of  strength 
between  two  persons,  by  grasping  the  hands  palm  to  palm,  wath  the 
elbows  resting  upon  a  table,  and  twisting,  when  the  humerus  has  sud- 
denly given  way  a  little  above  the  condyles.  I  have  seen  one  case  of 
this  kind,  which  was  under  the  care  of  Dr.  Winne,  of  this  city,  and 
Malgaigne  has  collected  five  other  similar  cases,  two  of  which  were 
reported  by  Lonsdale. 

The  example  of  fracture  during  birth,  to  which  I  have  referred,  oc- 
curred in  a  healthy  female  child,  whose  parents  were  also  healthy.  The 
mother  was  in  labor  six  or  eight  hours,  but  the  labor  was  not  severe. 
She  was  attended  by  a  midwife,  and  does  not  know  whether  violence 
was  employed  or  not.  Dr.  Lockwood,  of  Buffalo,  was  called  on  the 
third  day,  and  found  the  arm  broken  a  little  below  its  middle,  and 
moving  as  freely  as  it  did  at  the  elbow-joint ;  he  applied  lateral  splints, 
with  bandages,  &c.  I  saw  the  child  on  the  seventeenth  day  after  its 
birth,  with  Dr.  Lockwood.  There  was  then  a  perfect  ferule  of  en- 
sheathing  callus  surrounding  the  fragments,  and  which,  owing  to  the 
softness  of  the  flesh,  could  be  easily  detected  and  defined.  The  frag- 
ments were  firm,  and  had  been  at  least  three  or  four  days.  Nearly  a 
year  after,  I  again  examined  the  arm,  and  could  not  discover  any 
traces  of  the  accident. 

Dr.  Lciwenhardt  has  also  reported  a  case  in  which  the  evidence  was 
conclusive  that  the  fracture  was  caused  solely  by  the  contractions  of 
the  uterus,  which  forced  the  arm  against  the  pubes ;  the  arm  being 
heard  distinctly  to  snap  wben  it  was  passing  this  point,  and  while  the 
hands  of  the  accoucheur  were  not  aiding  in  the  delivery.  In  this  case 
the  humerus  was  broken  in  its  upper  third.^ 

'  Waters,  New  York  Journal  of  Medicine,  May,  1847,  p.   318,  vol.  viii.  First  Series. 
^  Van  Buren,  Ibid.,  January,  1654,  p.  152,  vol.  xii.  Second  Series. 
^  Lowenhardt,  American  Journal   of  Medical  Sciences,  January,  1S41,  p.  250,  from 
Medicin  Zeit.,  Mai  6,  lfe40. 


236 


FEACTURES    OF    THE    HUMEEUS. 


K. 


Seat  and  Direction  of  the  Fracture. —  The  seat  of  the  fracture  is  more 

often  below  than  above  the  middle  of  the  bone;  thus  I  have  found  the 

fracture  thirteen  times  near  the  middle,  and  the  same 

Fig.  59.  number  of  times  below  the  middle  third,  but  only  six 

/^^^        times  above  the   middle   third.     The  observations  of 

f  f'^wl        Norris,  who  found  four  fractures  of  the  shaft  above  the 

middle,  and  nine  below,  correspond  with  my  own  ;^  but 

M.  Gu^retin,  in  the  same  number  of  fractures,  found  nine 

above  the  middle  and  four  below.^ 

The  line  of  fracture  is  generally  oblique,  but  more 
often  transverse  than  in  fractures  of  the  clavicle,  femur, 
or  tibia. 

Displacement. — The  direction  of  the  displacement  de- 
pends, no  doubt,  sometimes  upon  the  precise  point  of 
the  fracture  and  upon  the  action  of  the  muscles  operat- 
ing upon  the  two  fragments;  thus,  if  the  fracture  takes 
place  just  above  the  insertion  of  the  deltoid,  the  lower 
fragment  is  liable  to  be  drawn  upwards  and  outwards, 
in  the  direction  of  its  fibres,  while  the  upper  fragment 
is  carried  toward  the  origin  of  the  pectoralis  major,  &c. ; 
but,  in  a  great  majority  of  cases,  the  influence  of  these 
muscles  is  more  than  counterbalanced  by  the  direction 
of  the  force  and  by  the  direction  of  the  fracture.  Practi- 
cally, therefore,  it  is  seldom  of  much  importance  to  de- 
termine the  exact  point  of  fracture,  as  to  whether  it  is 
just  al5ove  or  below  the  insertion  of  a  particular  muscle;  nor,  indeed, 
is  it  generally  very  easy  to  ascertain  this  point  with  much  precision. 

The  amount  of  displacement  varies  considerably  in  different  persons, 
and  in  fractures  at  different  points,  but  it  will  average  about  three- 
quarters  of  an  inch.  When  the  fracture  is  produced  by  muscular 
action  alone  it  is  generally  transverse,  and  displacement  seldom  occurs. 
Such  was  the  fact  in  every  instance  where  my  own  patient  broke  the 
arm  three  times  consecutively  at  different  points;  and  union  was  speedily 
accomplished,  and  with  no  deformity.  Dupuytren,  however,  saw  a  case 
which  constituted  an  exception  to  this  general  rule.  The  fragments 
became  completely  separated,  and  were  so  movable  that  union  could 
not  be  effected,  and  he  was  compelled,  after  three  months,  to  resort  to 
resection. 

Results. — In  twenty-three  examples,  the  average  shortening  is  about 
one-quarter  of  an  inch ;  but  of  these,  thirteen  are  not  shortened  at  all, 
so  that  the  average  of  shortening  in  the  remaining  ten  is  three-quar- 
ters of  an  inch  ;  the  amount  of  overlapping  varying  from  one-quarter 
of  an  inch  to  one  inch  and  a  quarter. 

In  twenty-eight  examples,  I  have  twice  seen  the  humerus  refuse  to 
unite ;  once  when  the  fracture  was  in  the  lower  third  of  the  shaft.  This 
was  an  oblique,  compound  fracture,  and  no  union  had  taken  place  at 
the  end  of  five  months.     The  man  was  intemperate,  but  in  pretty  good 


'  Norris,  Am.  Journ.  of  Med.  Sci.,  .January,  1842,  vol.  xxix.  p.  28. 
^  Gueretin,  Presse  Medicale,  vol.  i.  p.  45. 


SHAFT    BELOW   THE    SURGICAL    NECK.  237 

health.'  In  the  second  case,  the  fracture  had  occurred  a  little  below 
the  middle  of  the  bone,  and  it  was  simple.  Five  months  after  the 
accident  this  patient  consulted  me,  when  I  found  the  elbow  anchylosed, 
the  forearm  being  fixed  at  right  angles  with  the  arm.^  Neither  of 
these  patients  had  been  under  my  care  previously,  but  I  learned  that 
an  intelligent  Canadian  surgeon  had  treated  one  of  them,  and  the 
other  had  been  seen  and  treated  by  several  surgeons. 

In  two  other  cases,  the  elbow  remained  somewhat  stiff  a  long  time 
after  the  splints  were  removed ;  in  one  case,  complete  freedom  of 
motion  was  not  restored  at  the  end  of  fifteen  years. 

Generally,  however,  the  motions  of  the  elbow  joint  have  been  very 
soon  restored  after  the  removal  of  the  splints  and  sling. 

I  ought  to  mention  that,  not  unfrequently,  fractures  of  the  shaft  of 
the  humerus,  and  especially  where  they  are  occasioned  by  direct  blows, 
are  followed  by  great  swelling,  and  sometimes  by  abscesses.  In  one 
instance  the  fracture  having  taken  place  within  the  insertion  of  the 
deltoid  muscle,  the  sharp  extremity  of  the  lower  fragment  was  made 
to  penetrate  the  flesh,  causing  an  abscess,  and  finally  tetanus,  of  which 
my  patient  soon  died.  A  medical  gentleman,  and  a  friend  of  the 
family,  suggested  that  the  bone  had  not  been  properly  "  set,"  for  which 
omission  I  ought  to  be  held  responsible.  But,  fortunately  for  my  re- 
putation, the  friends  had  more  intelligence  than  the  doctor,  and  were 
able  to  appreciate  the  difficulty  of  "setting"  a  very  oblique  fracture. 

The  following  remarks  of  Malgaigne  are  too  pertinent  to  be  omitted 
in  this  connection:  "  When  there  is  great  obliquity,  with  overlapping, 
or  a  fracture  with  splintering,  or  a  multiple  fracture,  a  certain  amount 
of  deformity  is  inevitable,  and  the  formation  of  callus  demands  one  or 
two  weeks  more.  With  the  inflammation  comes  also  the  danger  of 
suppuration,  and  later,  a  rigidity  of  the  articulations  difficult  to  dissi- 
pate. In  short,  we  must  not  forget  that  of  all  fractures,  those  of  the 
humerus  are  most  liable  to  fail  of  consolidation." 

On  the  other  hand,  we  shall  find,  in  the  case  of  this  bone,  as  in  all 
others,  some  remarkable  exceptions,  where,  although  the  fracture  may 
be  compound,  and  badly  comminuted,  yet  the  limb  has  been  saved 
and  made  useful.  Ayres,  of  New  York,  reports  a  case  of  this  kind, 
in  which  he  removed  a  portion  of  the  shaft,  and  although  the  brachial 
artery  was  probably  obliterated,  a  good  union  took  place  ;^  and  Walker, 
of  Boston,  has  noticed  two  or  three  similar  examples.^ 

For  an  account  of  two  remarkable  cases  of  compound  fracture  of  the 
shaft  of  the  humerus,  illustrating  the  powers  of  Nature  in  childhood, 
in  the  restoration  of  broken  and  comminuted  bones,  the  reader  may 
consult,  in  the  New  York  Journal  of  Medicine  for  November,  1849,  a 
paper  entitled  "Amputations  and  Compound  Fractures,"  by  John  0. 
Stone,  Surgeon  to  Bellevue  Hospital.  The  accidents  occurred  in 
children,  one  of  whom  was  four,  and  the  other  six  years  of  age,  both 
of  whom  recovered  with  useful  arms. 

'  Report  on  Deformities,  &c.,  Case  33.  ^  Ibid.,  Case  21. 

^  Ayres,  New  York  Journal  of  Medicine,  January,  1857,  p.  24,  3d  series,  vol.  xi. 
''  Walker:  Essay  on  Compound  Fractures,  &c.,  by  William  J.  Walker,  of  Boston, 
published  in  London  in  1845. 


238 


FRACTUEES    OF    THE    HUMERUS. 


Treatment. — In  the  treatment  of  fractures  of  that  portion  of  the  shaft 
of  the  humerus  now  under  consideration,  I  have  preferred  generally  a 

broad  and  thick  splint  of  gutta  percha — felt 
may  answer  nearly  as  well — sufficiently 
long  to  extend  from  the  neck  to  the  wrist, 
moulded  accurately,  and  applied  to  the  out- 
side of  the  shoulder  and  arm,  while  the 
limb  is  flexed  to  a  right  angle,  and  while 
extension  is  being  made  upon  the  humerus. 
This  being  properly  padded,  and  secured 
in  place  by  rollers,  I  place  the  arm  in  a 
sling  beside  the  body.  The  sling  must, 
however,  be  so  arranged,  by  being  looped 
under  the  wrists,  and  not  under  the  elbow, 
as  that  the  weight  of  the  elbow  and  lower 
part  of  the  arm  may  aid  in  making  exten- 
sion. Welch's  splint  will  answer  the  same 
purpose;  or  three  narrow  splints  of  different 
lengths  may  be  used,  but  I  do  not  find  them 
so  convenient  as  Welch's,  or  gutta  percha  applied  as  I  have  directed 
above. 

Other  surgeons  have  sought  to  make  permanent  extension  in  these 
and  certain  other  fractures  of  the  humerus,  by  various  contrivances. 
Mr.  Lonsdale  constructed  an  instrument  which  might  be  lengthened 
or  shortened  to  suit  the  case;  it  was  made  of  steel,  and  was  worked 
with  a  screw  operating  upon  cogs  in  a  sliding  bar;  resembling,  in  some 
respects,  the  arm  portion  of  Jarvis's  adjuster.  In  the 
second  London  edition  of  a  series  of  plates  illustrat- 
ing the  action  of  the  muscles  in  producing  displace- 
ment in  fractures,  by  S.  W.  Hind,  is  a  drawing  of  an 
apparatus  invented  by  the  author  for  the  same  pur- 
pose, which  is  very  simple,  and  in  some  respects 
more  complete  than  Lonsdale's,  and  which  may  be 
easily  adapted  to  almost  any  form  of  arm-splint. 
Indeed,  nothing  more  is  necessary  than  to  attach  to 
the  ordinary  long  splint  a  movable  crutch. 

I  believe  that  all  these  contrivances  may  prove 
occasionally  useful,  but  the  common  experience  of 
surgeons  has  shown  how  difficult  it  is  to  accomplish 
much  extension  by  means  of  pressure  in  the  axilla ; 
a  mode,  too,  which  I  think  must  be  wholly  inadmis- 
sible when  the  fracture  approaches  the  upper  end, 
since  the  pressure  by  the  crutch-head  upon  the  pec- 
toralis  major  and  latissimus  dorsi,  which  constitute 
the  margins  of  the  axilla,  must  tend  to  displace  the 
fragments  upon  which  they  act,  inwardly,  and  which 
B.  Shaft,  c.  Elbow  rest,  scldom  cau  bc  applied  with  much  force  to  fractures 
E.  Hook  for  attachment  ^g^r  the  coudylcs,  ou  accouut  of  the  probablc  exist- 
of   bandage,  opposite  ^^  inflammation  and  swelling  about  the  joint. 

■which  IS  a  crossbar  tor  -,  r    i        •  ^    •  o       ^  i? 

the -same  purpose.  Malgaignc,  whcu   spcaking   01   the   apparatus   oi 


Lonsdale's  extension 
APPARATUS, — A.  Crutch. 


SHAFT  BELOW  THE  SUEGICAL  NECK.  239 

Lonsdale,  remarks:  "But  the  surgeon  should  never  lose  sight  of  the 
fact  that  permanent  extension  is  a  resource  always  dangerous,  often 
useless,  and  which  demands  in  its  application  much  caution  and 
watchfulness." 

The  following  example  will  illustrate  the  practical  difficulty  of  em- 
ploying permanent  extension  in  fractures  of  the  humerus: — 

A  laborer,  aged  thirty,  was  admitted  into  the  Buffalo  Hospital  of  the 
Sisters  of  Charity,  on  the  second  day  of  October,  1853,  with  a  simple 
oblique  fracture  of  the  humerus,  which  had  occurred  three  days  before. 
The  fracture  was  situated  within  the  insertion  of  the  deltoid,  and  hav- 
ing been  produced  by  the  rolling  of  a  log  upon  the  arm,  the  whole 
limb  was  much  swollen.  The  night  following  his  admission,  in  a  fit 
of  delirium  tremens,  he  removed  all  of  the  dressings.  When  I  visited 
the  wards  in  the  morning,  I  found  the  fragments  displaced  and  the 
muscles  contracting  violently.  The  ordinary  dressings  were  applied, 
and  continued  until  the  fifth  day,  when,  as  the  delirium  had  not  ceased, 
and  the  muscles  continued  to  contract  with  great  violence,  it  was  de- 
termined to  attempt  permanent  extension.  For  this  purpose  we  lifted 
the  elbow  upwards  and  outwards,  to  relax  the  deltoid,  and  then,  having 
made  extension  with  the  forearm  placed  at  a  right  angle  with  the  arm, 
we  fitted  carefully  a  large  gutta-percha  splint  to  the  forearm,  arm,  axilla, 
and  side,  in  such  a  manner  that  when  the  splint  was  secured  to  these 
several  parts,  the  arm  could  not  fall  to  the  side  of  the  body  completely, 
and  in  proportion  as  it  did  fall  downward,  it  would  make  extension 
upon  the  arm.  This  splint  was  well  padded,  and  secured  in  place  with 
rollers. 

On  the  sixth  day  the  delirium  had  ceased,  and  never  returned. 
The  dressings  were  well  in  place,  and  seemed  to  accomplish  the  indi- 
cation we  had  in  view ;  but,  on  the  seventh  day,  although  he  had  kept 
very  quiet,  everything  was  disarranged,  and  the  whole  had  to  be  re- 
adjusted. On  the  eighth  and  ninth,  the  same  thing  occurred.  During 
this  time  we  had  varied  the  dressings,  position,  &c.,  each  day,  to  meet, 
if  possible,  the  difficulties,  but  it  was  at  length  deemed  unwise  to  pur- 
sue the  attempt  any  further,  and  we  returned  to  the  use  of  the  ordinary 
splints,  laying  the  arm  against  the  side  of  the  body.  The  union  was 
finally  completed  without  either  overlapping  or  angular  displacement. 

Something  may  always  be  accomplished  when  the  patient  is  walking 
about,  by  allowing  the  elbow  to  escape  from  the  sling,  so  that  its  weight 
shall  make  constant  traction  upon  the  lower  fragment ;  and  the  plan 
which  I  suggested  some  years  since,  of  treating  certain  cases  of  de- 
layed union  of  the  humerus,  namely,  extending  the  arm  at  full  length 
by  the  side  of  the  body,  so  that  the  lower  fragment  shall  receive  the 
whole  weight  of  the  forearm  and  hand,  might  occasionally  prove  valua- 
ble in  recent  fractures  where  the  tendency  to  override  was  very  great. 
In  two  instances,  I  have  already  put  this  plan  sufficiently  to  the  test 
to  determine  its  safety  and  utility. 

The  precise  plan,  and  my  reasons  for  its  adoption  in  certain  cases  of 
delayed  union,  were  set  forth  in  the  following  paper,  read  before  the 
Buffalo  City  Medical  Association,  and  published  in  the  Buffalo  Medical 
Journal  for  Auo-ust,  1854. 


240  FEACTUEES    OF    THE    HUMEEUS. 

"I  have  observed  that  non-union  results  more  frequently  after  frac- 
tures of  the  shaft  of  the  humerus,  than  after  fractures  of  the  shaft  of 
any  other  bone. 

"Comparing  the  humerus  with  the  femur,  between  which,  above  all 
others,  the  circumstances  of  form,  situation,  &c.,  are  most  nearly  parallel, 
and  in  both  of  which  non-union  is  said  to  be  relatively  frequent,  I  find 
that  of  forty-nine  fractures  of  the  humerus,  four  occurred  through  the 
surgical  neck,  twelve  through  the  condyles,  and  twenty-nine  through 
the  shaft.  In  one  of  the  twenty-nine,  the  patient  survived  the  accident 
only  a  few  days.  In  four  of  the  remaining  tv/enty-eight,  union  had 
not  occurred  after  the  lapse  of  six  months,  and  in  many  more  it  was 
delayed  beyon4  the  usual  time.  Two  of  the  four  were  simple  frac- 
tures, and  occurred  near  the  middle  of  the  humerus ;  the  third  wak 
compound,  and  occurred  near  the  middle  also;  the  fourth  was  com- 
pound, and  occurred  near  the  condyles. 

"  This  analysis  supplies  us,  therefore,  with  four  cases  of  non-union, 
from  a  table  of  twenty-eight  cases  of  fractures  through  the  shaft. 

"  Of  eighty-seven  fractures  of  the  femur,  twenty  occurred  through 
the  neck,  one  through  the  trochanter  major,  and  one  through  the  con- 
dyles. The  remaining  sixty-five  occurred  through  the  shaft,  and  gene- 
rally near  the  middle,  and  not  in  one  case  was  the  union  delayed  be- 
yond six  months. 

"  To  make  the  comparison  more  complete,  I  must  add  that  of  the 
twenty-eight  fractures  of  the  shaft  of  the  humerus,  six  were  compound; 
and  of  the  sixty-five  fractures  of  the  shaft  of  the  femur,  six  were 
either  compound,  comminuted,  or  both  compound  and  comminuted. 
The  six  compound  fractures  of  the  shaft  of  the  humerus  furnished  two 
cases  of  non-union.  The  six  cases  of  either  compound  or  comminuted, 
or  compound  and  comminuted  fractures  of  the  femur,  furnished  no 
case  of  non-union. 

"  I  beg  to  suggest  to  the  Society  what  seems  to  me  to  be  the  true 
explanation  of  these  facts. 

"  It  is  the  universal  practice,  so  far  as  I  know,  in  dressing  fractures 
of  the  humerus,  to  place  the  forearm  at  a  right  angle  with  the  arm. 
Within  a  few  days,  and,  generally,  I  think,  within  a  few  hours,  after 
the  arm  and  forearm  are  placed  in  this  position,  a  rigidity  of  the  mus- 
cles and  other  structures  has  ensued,  and  to  such  a  degree  that  if  the 
splints  and  sling  are  completely  removed,  the  elbow  will  remain  flexed 
and  firm;  nor  will  it  be  easy  to  straighten  it.  A  temporary  false  an- 
chylosis has  occurred,  and  instead  of  motion  at  the  elbow-joint,  when 
the  forearm  is  attempted  to  be  straightened  upon  the  arm,  there  is  only 
motion  at  the  seat  of  fracture.  It  will  thus  happen  that  every  upward 
and  downward  movement  of  the  forearm  will  inflict  motion  upon  the 
fracture;  and  inasmuch  as  the  elbow  has  become  the  pivot,  the  motion 
at  the  upper  end  of  the  lower  fragment  will  be  the  greater  in  propor- 
tion to  the  distance  of  the  fracture  from  the  elbow-joint. 

"  No  doubt  it  is  intended  that  the  dressings  shall  prevent  all  motion 
of  the  forearm  upon  the  arm;  but  I  fear  that  they  cannot  always  be 
made  to  do  this.  I  believe  it  is  never  done  when  the  dressing  is  made 
without  angular  splints,  nor  is  it  by  any  means  certain  that  it  will  be 


SHAFT    BELOW    THE    SURGICAL    NECK.  241 

accomplished  when  such  splints  are  used.  The  weight  of  the  forearm 
is  such,  when  placed  at  a  right  angle  with  the  arm,  and  encumbered 
with  splints  and  bandages,  that  even  when  supported  bj  a  sling,  it 
settles  heavily  forwards,  and  compels  the  arm-dressings  to  loosen  them- 
selves from  the  arm  in  front  of  the  point  of  fracture,  and  to  indent 
themselves  in  the  skin  and  flesh  behind.  By  these  means  the  upper 
end  of  the  lower  fragment  is  tilted  forwards.  If  the  forearm  should 
continue  to  drag  upon  the  sling,  nothing  but  a  permanent  forward 
displacement  would  probably  result.  The  bones  might  unite,  yet  with 
a  deformity. 

But  the  weight  of  the  forearm  under  these  circumstances  is  not 
uniform,  nor  do  I  see  how  it  can  be  made  so.  It  is  to  the  sling  that 
we  must  trust  mainly  to  accomplish  this  important  indication.  But 
you  have  all  noticed  that  the  tension  or  relaxation  of  the  sling  depends 
upon  the  attitude  of  the  body,  whether  standing  or  sitting ;  upon  the 
erection  or  inclination  of  the  head  ;  upon  the  motions  of  the  shoulders ; 
and  in  no  inconsiderable  degree  upon  the  actions  of  respiration.  Nor 
does  the  patient  himself  cease  to  add  to  these  conditions  by  lifting  the 
forearm  with  his  opposite  hand  whenever  provoked  to  it  by  a  sense  of 
fatigue. 

This  difficulty  of  maintaining  quiet  apposition  of  the  fragments 
while  the  arm  is  in  this  position,  at  whatever  point  it  may  be  broken, 
becomes  more  and  more  serious  as  we  depart  from  the  elbow-joint, 
and  would  be  at  its  maximum  at  the  upper  end  of  the  humerus,  were 
it  not  that  here  a  mass  of  muscles,  investing  and  adhering  to  the  bone, 
in  some  measure  obviates  the  difficulty.  Its  true  maximum  is,  there- 
fore, near  the  middle,  where  there  is  less  muscular  investment,  and 
where,  on  the  one  hand,  the  fracture  is  sufficiently  remote  from  the 
pivot  or  fulcrum  to  have  the  motion  of  the  upper  end  of  the  lower 
fragment  multiplied  through  a  long  arm,  while,  on  the  other  hand,  it 
is  sufficiently  near  the  armpit  and  shoulder  to  prevent  the  upper 
portion  of  the  splint  and  arm-dressings  from  obtaining  a  secure  grasp 
upon  the  lower  end  of  the  upper  fragment. 

It  must  not  be  overlooked  that  the  motion  of  which  we  speak 
belongs  exclusively  to  the  lower  fragment,  and  that  it  is  always  in  the 
same  plane  forwards  and  backwards,  but  especially  that  it  is  not  a 
motion  upon  the  fracture  as  upon  a  pivot,  but  a  motion  of  one  frag- 
ment to  and  from  its  fellow.  This  circumstance  I  regard  as  important 
to  a  right  appreciation  of  the  difficulty.  Motion  alone,  I  am  fully 
convinced,  does  not  so  often  prevent  union  as  surgeons  have  generally 
believed.  It  is  exceedingly  rare  to  see  a  case  of  non-union  of  the 
clavicle.  Of  forty-seven  cases  of  fracture  of  the  clavicle  which  have 
come  under  my  observation,  and  in  by  far  the  greater  proportion 
of  which  considerable  overlapping  and  consequent  deformity  ensued, 
only  one  has  resulted  in  non-union,  and  in  this  instance  no  treatment 
whatever  was  practised,  but  from  the  time  of  the  accident  the  patient 
continued  to  labor  in  the  fields  and  hold  the  plough  as  if  nothing  had 
occurred.  I  have,  therefore,  seen  no  case  of  non-union  of  the  clavicle 
where  a  surgeon  has  treated  the  accident.  Indeed,  what  is  most  perti- 
nent and  remarkable,  its  union  is  more  speedy  usually  than  that  of  any 
16 


242  FEACTURES    OF    THE    HUMEEUS. 

other  bone  in  the  body  of  the  same  size.  Yet  to  prevent  motion  of 
the  fragments  in  a  case  of  fractured  clavicle  with  complete  separation 
and  displacement,  except  where  the  fracture  is  near  one  of  the  ex- 
tremities of  the  bone,  I  have  always  found  wholly  impracticable. 
Whatever  bandages  or  apparatus  has  been  applied,  I  have  still  seen 
always  that  the  fragments  would  move  freely  upon  each  other  at  each 
act  of  inspiration  and  expiration,  and  at  almost  every  motion  of  the 
head,  body,  or  upper  extremities.  It  is  probable,  gentlemen,  that  you 
have  made  the  same  observation. 

From  this  and  many  similar  facts  I  have  been  led  to  suspect,  for  a 
long  time,  that  motion  has  had  less  to  do  with  non-nnion  than  was 
generally  believed. 

I  find,  however,  no  difficulty  in  reconciling  this  suspicion  with  my 
doctrine  in  reference  to  the  case  in  question ;  and  it  is  precisely  be- 
cause, as  I  have  already  explained,  the  motion,  in  case  of  a  fractured 
humerus,  dressed  in  the  usual  manner,  is  peculiar. 

In  a  fracture  of  the  clavicle  through  its  middle  third  (its  usual  situa- 
tion), the  motion  is  upon  the  point  of  the  fracture  as  upon  a  pivot; 
although,  therefore,  the  motion  is  almost  incessant,  it  does  not  essen- 
tially, if  at  all,  disturb  the  adhesive  process.  The  same  is  true  in 
nearly  all  other  fractures.  The  fragments  move  only  upon  themselves, 
and  not  to  and  from  each  other.  I  know  of  no  complete  exception 
but  in  the  case  now  under  consideration. 

Aside  from  any  speculation,  the  facts  are  easily  verified  by  a  per- 
sonal examination  of  the  patients  during  the  first  or  second  week  of 
treatment,  or  at  any  time  before  union  has  occurred,  both  in  fractures 
of  the  humerus  and  clavicle.  The  latter  is  always  sufficiently  exposed 
to  permit  you  to  see  what  occurs,  and  as  soon  as  the  swelling  has  a 
little  subsided  in  the  former  case  you  will  have  no  difficulty  in  feeling 
the  motion  outside  of  the  dressings,  or,  perhaps,  in  introducing  the 
finger  under  the  dressings  sufficiently  far  to  reach  the  point  of  fracture. 
I  believe  you  will  not  fail  to  recognize  the  difference  in  the  motion 
between  the  two  cases.  Such,  gentlemen,  is  the  explanation  which  I 
wish  to  offer  for  the  relative  frequency  of  this  very  serious  accident — 
non-union  of  the  humerus. 

I  know  of  no  other  circumstance  or  condition  in  which  this  bone  is 
peculiar,  and  which,  therefore,  might  be  invoked  as  an  explanation. 
Overlapping  of  the  bones,  the  cause  assigned  by  some  writers,  is  not 
sufficient,  since  it  is  not  peculiar.  The  same  occurs  much  oftener,  and 
to  a  much  greater  extent,  in  fractures  of  the  femur,  and  equally  as 
often  in  fractures  of  the  clavicle,  yet  in  neither  case  are  these  results 
so  frequent.  Nor  can  it  be  due  to  the  action  of  the  deltoid  muscle,  or 
of  any  other  particular  muscles  about  the  arm,  whether  the  fracture 
be  below  or  above  their  insertions,  since  similar  muscles,  with  similar 
attachments,  on  the  femur  and  on  the  clavicle,  tending  always  power- 
fully to  the  separation  of  the  fragments,  occasion  deformity,  but  they 
seldom  prevent  union. 

If  I  am  correct  in  my  views,  we  shall  be  able  sometimes  to  consum- 
mate union  of  a  fractured  humerus  where  it  is  delayed,  by  straightening 
the  forearm  upon  the  arm,  and  confining  them  to  this  position.     A 


SHAFT    BELOW    THE    SURGICAL    NECK.  243 

straight  splint,  extending  from  the  top  of  the  shoulder  to  the  hand, 
constructed  from  some  firm  material,  and  made  fast  with  rollers,  will 
secure  the  requisite  immobility  to  the  fracture.  The  weight  of  the 
forearm  and  hand  will  only  tend  to  keep  the  fragments  in  place,  and 
if  the  splint  and  bandages  are  sufficiently  tight,  the  motion  occa- 
sioned by  swinging  the  hand  and  forearm  will  be  conveyed  almost 
entirely  to  the  shoulder-joint.  Very  little  motion,  indeed,  can  in  this 
posture  be  communicated  to  the  fragments,  and  what  little  is  thus 
communicated,  is  a  motion  which  experience  has  elsewhere  shown  not 
disturbing  or  pernicious,  but  a  motion  only  upon  the  ends  of  the  frag- 
ments, as  upon  a  pivot. 

I  do  not  fail  to  notice  that  this  position  has  serious  objections,  and 
that  it  is  liable  to  inconveniences  which  must  always,  probably,  pre- 
vent its  being  adopted  as  the  usual  plan  of  treatment  for  fractured 
arms.  It  is  more  inconvenient  to  get  up  and  lie  down,  or  even  to  sit 
down,  in  this  position  of  the  arm,  and  the  hand  is  liable  to  swell. 
But  I  shall  not  be  surprised  to  learn  that  experience  will  prove  these 
objections  to  have  less  weight  than  we  are  now  disposed  to  give  them. 
Eemember,  the  practice  is  yet  untried — if  I  except  the  case  which  I 
am  about  to  relate,  and  in  which  case,  I  am  free  to  say,  these  ob- 
jections scarcely  existed.  The  swelling  of  the  hand  was  trivial,  and 
only  continued  through  the  first  fortnight,  and  the  patient  never 
spoke  of  the  inconvenience  of  getting  up  or  sitting  down,  or  even  of 
lying  down. 

The  following  is  the  case  to  which  I  have  just  referred  :  "  Michael 
Mahar,  laborer,  set.  35,  broke  his  left  humerus  just  below  its  middle, 
Dec.  14th,  1853.  The  arm  was  dressed  by  a  surgeon  in  Canada  West, 
and  who  is  well  known  to  me  as  exceedingly  '  clever.'  After  a  few 
days  from  the  time  of  the  accident,  '  the  starch  bandage  was  put  on 
as  tight  as  it  could  be  borne,  and  brought  down  on  the  forearm,  so 
as  to  confine  the  motions  of  the  elbow-joint.'  Six  weeks  after  the 
injury,  Jan.  29th,  1854,  Mahar  applied  to  me  at  the  Hospital.  No 
union  had  occurred.  The  motion  between  the  fragments  was  very 
free,  so  that  they  passed  each  other  with  an  audible  click.  There  was 
little  or  no  swelling  or  soreness.  In  short,  everything  indicated  that 
union  was  not  likely  to  occur  without  operative  interference.  The 
elbow  was  completely  anchylosed.  I  explained  to  my  students  what 
seemed  to  me  to  be  the  cause  of  the  delayed  union,  and  declared  to 
them  that  I  did  not  intend  to  attempt  to  establish  adhesive  action 
until  I  had  straightened  the  arm.  They  had  just  witnessed  the  failure 
of  a  precisely  similar  case,  in  which  I  had  made  the  attempt  to  bring 
about  union  without  previously  straightening  the  arm. 

"  On  the  6th  of  Feb.,  1854,  we  had  succeeded  in  making  the  arm  nearly 
straight.  I  now  punctured  the  upper  end  of  the  lower  fragment  with 
a  small  steel  instrument,  and,  as  well  as  I  was  able,  thrust  it  between 
the  fragments.  Assisted  by  Dr.  Boardman,  I  then  applied  a  gutta- 
percha splint  from  the  top  of  the  shoulder  to  the  fingers,  moulding  it 
carefully  to  the  whole  of  the  back  and  sides  of  the  limb,  and  securing 
it  firmly  with  a  paste  roller.  March  4th  (not  quite  four  weeks  after 
the  application  of  the  splint)  we  opened  the  dressings  for  the  second 


244  FRACTURES    OF    THE    HUMERUS. 

time,  and  carefully  renewed  them.  A  slight  motion  was  yet  percep- 
tible between  the  fragments.  March  18th,  we  opened  the  dressings  for 
the  third  time,  and  found  the  union  complete.  This  was  within  less 
than  forty  days.  The  patient  was  now  dismissed.  On  the  29th  of 
April  following,  the  bone  was  re-fractured.  Mahar  had  been  assisting 
to  load  the  'tender'  to  a  locomotive.  As  the  train  was  just  getting 
in  motion,  he  was  hanging  to  the  tender  by  his  sound  arm,  while 
another  laborer  seized  upon  his  broken  arm  to  keep  himself  upon  the 
car,  and  with  a  violent  and  sudden  pull  wrenched  him  from  the  tender 
and  reproduced  the  fracture.  The  next  morning  I  applied  the  dress- 
ings as  before,  and  did  not  remove  them  during  three  weeks;  at  the 
end  of  which  time  the  union  was  again  complete.  The  splint  was, 
however,  reapplied,  and  has  been  continued  to  this  time — a  period  of 
about  six  weeks."^ 

Since  the  date  of  the  above  paper,  I  have  twice  had  opportunities 
to  test  the  value  of  this  mode  of  treatment  in  cases  of  somewhat 
delayed  union  of  the  humerus,  and  in  each  case  with  the  same  favor- 
able result. 


§  6.  Base  of  the  Condyles.  {Fractures  de  Vextremite  inferieure  de 
Vhumerus. — Dupuytren.  Fractures  sus-condyliennes  de  Vhumerus. — Mal- 
gaigne.) 

Causes. — Of  thirteen  fractures  at  this  point,  nine  occurred  in  children 
under' ten  years  of  age,  the  youngest  being  two  years  old. 

In  nine  cases,  the  fracture  had  been  produced  by  a  fall,  and  it  is 
presumed  that  the  blow  was  received  upon  the  elbow ;  in  the  remain- 
Fig.  62. 


Fracture  at  the  base  of  the  condyles. 


ing  four  cases  the  cause  is  not  stated.  I  believe,  therefore,  that  this 
fracture  is  generally  the  result  of  an  indirect  blow  inflicted  upon  the 
extremity  of  the  elbow ;  in  a  few  examples,  it  has  been  produced  by 
a  blow  received  directly  upon  the  point  of  fracture,  as  by  the  kick  of 
a  horse,  &c.,  but  I  have  never  been  able  to  trace  it  to  a  fall  upon  the 
hand.  Eecently,  however,  an  "eclectic"  physician  in  Cincinnati  claimed 
that  he  had  met  with  this  fracture  in  a  lad  fourteen  years  old,  produced 

'  Buffalo  Med.  Journ.,  vol.  x.  pp.  14-147. 


BASE    OF    THE    CONDYLES.  245 

bj  a  fall  upon  the  palm  of  the  hand.  Subsequently  the  parents  of  the 
lad  sued  the  doctor  for  damages,  claiming  that  the  accident  was  a  dis- 
location of  the  radius  and  ulna  backwards,  as  it  is,  indeed,  quite 
probable  that  it  was ;  and  alleging  that  his  arm  has  been  maimed  by 
the  long-continued,  too  tight  and  unnecessary  bandaging. 

Direction  of  the  Fracture^  Displacement^  and  Symptoms. — I  think  this 
fracture  is  generally  oblique,  and  its  line  of  direction  upwards  and 
backwards;  in  seven  of  the  nine  cases  where  this  point  was  de- 
termined, such  has  been  its  apparent  direction,  and  the  lower  frag- 
ment has  been  found  drawn  up  behind  the  upper.  Once  I  have  found 
the  lower  fragment  in  front,  and  once  on  the  outside  of  the  upper. 

Three  of  the  thirteen  were  compound,  comminuted  fractures,  this 
being  a  larger  proportion  of  serious  complications  than  I  have  found 
in  almost  any  other  fracture  of  a  long  bone. 

I  have  never  met  with  what  I  supposed  to  be  a  separation  of  the 
lower  epiphysis,  but  surgical  writers  have  occasionally  spoken  of  this 
accident,  and  Dr.  Watson,  of  New  York,  believes  that  he  has  seen  one 
example  in  an  infant  not  quite  two  years  old.  The  limb  had  been 
violently  wrenched  by  the  mother,  in  attempting  to  lift  her.  She  was 
not  seen  by  Dr.  Watson  until  the  fourth  day,  at  which  time  the  swell- 
ing was  such  that  the  diagnosis  could  not  be  easily  made  out ;  but  on 
the  ninth  day  "it  was  apparent  that  the  shaft  of  the  humerus  had  been 
separated  from  its  cartilaginous  expansion  at  the  condyles,  near  the 
elbow."  By  the  use  of  angular  pasteboard  splints,  the  reduction  was 
maintained,  and  the  fragments  became  united  after  about  four  or  six 
weeks.' 

The  diagnosis  of  this  fracture  is  attended  with  peculiar  difficulties, 
and  it  has  occasionally  been  mistaken  for  a  dislocation  of  the  radius 
and  ulna  backwards.  Dupuytren  says:  "  There  is  nothing  so  common 
as  to  see  a  fracture  of  the  lower  end  of  the  humerus,  immediately 
above  the  elbow-joint,  mistaken  for  a  dislocation  backward ;"  and  he 
mentions  three  cases  which  have  come  under  his  own  observation.  I 
have  found  an  opposite  error,  however,  by  far  the  most  frequent, 
namely — a  dislocation  of  both  bones  backwards  has  been  supposed  to 
be  a  fracture. 

The  sources  of  this  embarrassment  are  found  in  the  proximity  of 
the  fracture  to  the  joint,  in  the  rapidity  with  which  swelling  occurs, 
and  in  the  striking  similarity  of  the  symptoms  which  characterize  the 
two  accidents. 

It  will  be  necessary,  therefore,  to  establish  with  care  the  differential 
diagnosis.     The  following  are  the  signs  of  fracture : — 

1.  Preternatural  mobility,  which,  owing  to  the  rapidity  of  the  swell- 
ing and  the  contraction  of  the  muscles  whose  tendons  are  stretched 
over  the  projecting  ends  of  the  bones,  is  often  soon  lost,  being  suc- 
ceeded, sometimes  after  a  few  hours,  by  a  rigidity  equal  to  that  which 
is  usually  present  in  dislocations,  or  even  greater.  It  is  especially 
difficult  to  flex  the  arm,  owing  to  the  pressure  by  the  upper  fragment 
into  the  bend  of  the  elbow. 

'  Watson,  New  York  Journ.  Med.,  Nov.  1853,  p.  430,  second  series,  vol.  xi. 


246  FRACTUEES    OF    THE    HUMERUS. 

2,  Crepitus.  This  can  usually  be  detected  at  any  period  if  the  arm 
is  sufficiently  extended,  so  as  to  bring  the  broken  surfaces  again  into 
apposition. 

8.  When  the  extension  is  sufficient,  reduction  is  easily  effected,  and 
the  natural  length  of  the  arm  is  restored,  but  the  limb  immediately 
shortens  when  the  extension  is  discontinued — especially  if  at  the  same 
moment  the  elbow  is  bent.  This  is  a  very  important  means  of  diag- 
nosis. 

4.  A  careful  measurement,  made  from  the  point  of  the  internal  con- 
dyle to  the  acromion  process,  declares  a  positive  shortening  of  the 
humerus. 

5.  By  flexing  and  extending  the  forearm  upon  the  arm,  while  the 
fingers  are  placed  upon  the  lower  portion  of  the  humerus,  the  project- 
ing fragments  can  be  felt.  Generally,  the  upper  fragment  being  in 
front  of  the  lower,  and  pressing  down  into  the  bend  of  the  elbow,  its 
end  cannot  be  so  easily  recognized ;  but  the  upper  end  of  the  lower 
fragment  can  easily  be  made  out  when  the  forearm  is  considerably 
flexed.  The  lower  end  of  the  upper  fragment  feels  more  rough,  and 
is  less  wide,  than  in  dislocations. 

6.  The  whole  of  the  lower  fragment  is  carried  backwards,  and  with 
it  the  radius  and  ulna,  producing  a  striking  prominence  of  the  elbow 
and  olecranon  process.  Efforts  to  straighten  the  forearm  upon  the 
arm,  when  no  extension  is  used,  increase  rather  than  diminish  this 
projection. 

7.  The  forearm  is  slightly  flexed  upon  the  arm ;  the  angle  made  at 
the  elbow  being  about  25  or  30  deg. 

8.  The  hand  and  forearm  are  proned. 

9.  The  relations  of  the  olecranon  process  with  the  two  condyles  re- 
main unchanged. 

Signs  of  a  dislocation  of  the  radius  and  ulna  hachvjards. 

1.  Preternatural  rigidity. 

2.  Absence  of  crepitus.  It  is  in  this  joint  especially  that  surgeons 
have  been  deceived  by  the  chafing  of  the  dislocated  bones  upon  the 
inflamed  joint  surfaces,  and  have  supposed  that  they  discovered  crepitus 
when  no  fracture  existed.  The  rapidity  with  which  inflammation  de- 
velops itself  after  dislocations  of  the  elbow  joint,  and  the  consequent 
abundant  effusion  of  lymph,  afford  the  probable  explanation  of  this 
frequent  error. 

3.  When  reduced,  the  bones  are  not  generally  disposed  to  become 
again  displaced,  even  though  the  elbow  should  be  flexed. 

4.  The  humerus  is  not  shortened,  but  the  olecranon  process  ap- 
proaches the  acromion  process. 

5.  There  are  no  sharp  projecting  points  of  bone.  The  lower  end 
of  the  humerus  may  not  always  be  felt  in  the  bend  of  the  elbow ;  but 
when  it  is  felt,  it  is  found  to  be  relatively  smooth,  broad  and  round. 

6.  A  remarkable  prominence  of  the  elbow  and  olecranon  process, 
which  prominence  is  sensibly  diminished  when  an  effort  is  made  to 
straighten  the  forearm  on  the  arm. 

7.  Forearm  flexed  upon  the  arm  to  about  the  same  degree  as  in  frac- 
ture. 


BASE    OF    THE    CONDYLES.  247 

8.  Hand  and  forearm  proned,  precisely  as  in  fracture. 

9.  Relations  of  the  olecranon  process  to  the  condyles  changed  very 
greatly. 

The  most  constant  diagnostic  signs  are,  then,  in  the  case  of  a  frac- 
ture— crepitus,  shortening  of  the  humerus,  projection  of  the  sharp 
ends  of  the  fragments,  and  an  increase  of  the  projection  of  the  elbow 
when  an  attempt  is  made  to  straighten  the  arm ;  and  in  the  case  of  a 
dislocation,  the  absence  of  crepitus,  humerus  not  shortened,  while  the 
olecranon  approaches  the  acromion  process ;  the  smooth,  round  head 
of  the  humerus  lost,  or  indistinctly  felt  in  the  bend  of  the  elbow  and 
the  projection  of  the  point  of  the  elbow  diminished  when  an  attempt 
is  made  to  straighten  the  forearm  on  the  arm. 

It  is  proper,  also,  to  repeat  here  what  we  have  already  said  in  rela- 
tion to  the  causes  of  this  fracture.  A  fracture  at  this  point  is  pro- 
duced almost  always  by  a  fall  upon  the  elbow,  but  a  dislocation  of  the 
radius  and  ulna  backwards  can  never  be.  On  the  other  hand,  a  dislo- 
cation is  produced  in  almost  every  instance  by  a  fall  upon  the  palm 
of  the  hand,  but  I  have  never  known  a  fracture  above  the  condjdes  to 
be  thus  produced. 

Results. — Eight  times  have  I  found  the  arm  shortened  from  half  an 
inch  to  one  inch,  or  a  little  more. 

Muscular  anchylosis  is  almost  always  present  when  the  apparatus 
is  first  removed,  and  it  is  seldom  completely  dissipated  until  after 
several  months ;  but  I  have  found  more  or  less  anchylosis  at  seven 
and  nine  months;  and  twice  after  the  lapse  of  three  years  the  motions 
of  the  joint  have  been  very  limited.  A  few  years  since,  I  examined 
the  arm  of  a  gentleman  who  was  then  twenty-seven  years  old,  and 
who  informed  me  that  when  he  was  four  years  old  he  broke  the 
humerus  just  above  the  condyles.  There  still  remained  a  sensible 
deformity  at  the  point  of  fracture — he  could  not  completely  supine 
the  arm.  The  whole  arm  was  weak,  and  the  ulnar  nerve  remarkably 
sensitive.  The  ulnar  side  of  the  forearm,  and  also  the  ring  and  little 
fingers,  were  numb,  and  have  been  in  this  condition  ever  since  the 
accident.  I  know  the  surgeon  very  well  who  had  charge  of  this  case, 
and  I  have  no  doubt  that  the  treatment  was  carefully  and  skilfully 
applied. 

In  June,  of  1850,  I  operated  upon  a  lad,  nine  years  old,  by  sawing 
off  the  projecting  end  of  the  upper  fragment,  whose  arm  had  been 
broken  nine  months  before.  This  fragment  was  lying  in  front  of  the 
lower,  and  the  skin  covering  its  sharp  point  was  very  thin  and  tender. 
There  was  no  anchylosis  at  the  elbow-joint,  but  the  hand  was  flexed 
forcibly  upon  the  wrist,  the  first  phalanx  of  all  the  fingers  extended, 
and  the  second  and  third  flexed.  Supination  and  pronation  of  the 
forearm  were  lost.  The  forearm  and  hand  were  almost  completely 
paralyzed,  but  very  painful  at  times.  The  median  nerve  could  be  felt 
lying  across  the  end  of  the  bone. 

In  the  hope  that  some  favorable  change  might  result  to  the  hand 
by  relieving  the  pressure  upon  the  nerve,  yet  with  not  much  expecta- 
tion of  success,  I  exposed  the  bone  and  removed  the  projecting  frag- 
ment.    The  nerve  had  to  be  lifted  and  laid  aside.     About  one  year 


248  FEACTURES    OF    THE    HUMERUS. 

from  this  time  I  found  the  arm  in  the  same  condition  as  before  the 
operation. 

Non-union  is  a  result  not  so  frequent  in  fractures  at  this  point  as 
higher  up ;  but  Stephen  Smith,  of  the  Bellevue  Hospital,  New  York, 
reports  a  case  of  non-union  in  a  young  man  of  twentj-three  years.  He 
was  admitted  to  the  hospital  on  the  seventh  day  after  the  accident. 
The  fracture  was  simple  and  transverse,  yet  at  the  end  of  four  months 
he  was  dismissed  "with  perfectly  free  motion  at  the  point  of  fracture."^ 
The  failure  to  unite  was  attributed  to  a  syphilitic  taint. 

A  case  was  recently  tried  iu  the  Supreme  Court  at  Brooklyn,  N.  Y., 
in  which,  after  a  simple  fracture  at  this  point,  the  arm  being  dressed 
with  splints  and  bandages,  the  little  finger  sloughed  off,  in  a  condition 
of  dry  gangrene,  and  the  adjacent  parts  of  the  hand  were  attacked 
with  humid  mortification,  Drs.  Parker  and  Prince  believed  that  this 
serious  accident  was  the  result  of  bandages  applied,  too  tightly  and 
suffered  to  remain  too  long,  while  Drs.  Valentine  Mott,  Rogers,  Wood, 
Ayres,  Dixon,  and  others,  believed  that  the  gangrene  might  have  been 
due  to  other  causes  over  which  the  surgeon  had  no  control.^ 

A  few  years  ago,  a  similar  case  occurred  in  the  town  of  Spencer, 
Tioga  Co.,  N.  Y.;  a  boy,  six  years  old,  having  broken  his  humerus 
just  above  the  condyles.  The  fracture  was  oblique.  The  surgeon 
who  was  called  to  treat  the  case  was  an  old  and  highly  respectable 
practitioner.  I  am  not  informed  of  the  plan  of  treatment  any  farther 
than  that  a  roller  was  applied.  On  the  eighth  day,  a  second  surgeon 
was  employed,  who,  finding  the  hand  cold  and  insensible,  removed  all 
of  the 'dressings;  after  which  the  thumb  and  forefinger  sloughed,  with 
other  portions  of  the  skin  and  flesh  of  the  hand  and  arm.  The  sur- 
geon who  was  first  in  attendance  was  prosecuted,  and  the  case  was 
tried  in  the  Supreme  Court  of  that  county,  but  the  jury  found  no 
cause  of  action.  Dr.  Hawley,  of  Ithaca,  and  the  late  Dr.  Webster,  of 
Geneva  Medical  College,  testified  that,  in  their  opinion,  the  death  of 
the  fingers  was  owing  to  the  pressure  of  the  fragment  upon  the  bra- 
chial artery,  and  not  to  the  tightness  of  the  bandages. 

Dr.  Gross  has  also  informed  us  of  still  another  case  of  the  same 
character,  which  occurred  in  Warren  Co.,  Ky.  A  boy,  ten  years  old' 
had  broken  h's  arm  above  the  condyles,  and  his  parents  having  em- 
ployed a  surgeon  residing  at  some  distance,  the  dressings  were  applied, 
and  directions  given  to  send  for  the  surgeon  whenever  it  became 
necessary.  The  parents  saw  the  arm  swell  excessively,  and  knew  that 
the  boy  was  suffering  very  much,  but  did  not  notify  the  surgeon  until 
the  tenth  day,  when  the  hand  was  found  to  be  in  a  condition  of  mor- 
tification, and  at  length  amputation  became  necessary. 

Long  afterward,  in  the  year  1851,  when  the  boy  became  of  age,  he 
prosecuted  his  surgeon,  but  with  no  result  to  either  party  beyond  the 
payment  of  their  respective  costs. 

While  I  would  not  deny  that  in  all  of  these  cases  the  sloughing 
might  have  been  solely  due  to  the  tightness  of  the  bandages,  against 

'  S.  Smith,  New  York  Journal  of  Medicine,  May,  1857,  p.  386,  third  series,  vol.  ii. 
2  New  York  Medical  Gazette,  vol.  xii.  pp.  46,  80,  111. 


BASE    OF    THE    CONDYLES. 


249 


which  cruel  and  mischievous  practice  we  cannot  too  loudly  declaim,  a 
knowledge  of  the  anatomy  of  these  parts,  and  the  opinions  of  the  very 
distinguished  gentlemen  who  testified  in  defence  of  these  surgeons, 
must  compel  us  to  admit  the  possibility  of  such  accidents  where  the 
treatment  has  been  skilful  and  faultless. 

Treatment. — The  splints  generally  employed  in  this  country,  in  frac- 
tures about  the  elbow-joint,  are  simple  angular  side  splints,  without 
joints,  such  as  those  recommended  by  Physick.^ 


Fig.  63. 


Fig.  64. 


Fergusson's  dressing  for  lower  part  of  arm. 


Physick's  elbow  splints. 


Angular  pasteboard  splints,  felt,  gutta  percha,  &c,,  or  angular  splints 
with  a  hinge,  such  as  Kirkbride's,^  Thomas  Hewson's,  Day's,  or  Rose's, 
or  the  more  perfect  and  elegant  angular  splint  of  ^Velch. 


Fig.  65. 


Fig.  66. 


Kirkbride's  elbow  splint, 


Kirkbride's  splint,  which  has  been  used  in  the  Pennsylvania  Hospi- 
tal in  several  instances,  is  composed  of  two  pieces  of  board,  connected 
together  by  a  circular  joint,  and  having  eyes  on  the  inner  edge,  two 
inches  apart,  and  holes  through  the  splint  at  graduated  distances  be- 

'  Elements  of  Surgery,  by  John  Syng  Dorsey,  Philadelphia  edition,  vol.  i.  p.  145. 
*  American  Journal  of  the  Medical  Sciences,  vol.  xvi.  p.  315. 


250 


FEACTUEES    OF    THE    HUMEEUS. 


tween  them.  There  is  also  a  swivel  eye,  passing  through  the  upper 
part  of  the  splint,  and  riveted  below.  A  wire  is  fastened  to  the 
swivel,  and  bent  at  right  angles  at  its  other  extremity,  of  a  size  to  fit 


Fig.  67. 


Fig.  68. 


Eose's  splint. 


Welch's  splint.   The  hinges  may  be  transferred  to  splints 
of  different  sizes. 

the  eyes  and  holes  in  the  splint.  This  splint,  properly  supported  by 
pads,  is  to  be  placed  either  upon  the  outside  or  inside  of  the  arm,  and 
secured  by  rollers.  When  the  angle  is  to  be  changed,  the  wire  is  un- 
hooked and  removed  to  another  eye,  or  to  some  of  the  intermediate 
holes  upon  the  side  of  the  splint.  Dr.  Kirkbride  reports  two  cases  of 
fracture  of  the  lower  part  of  the  humerus  treated  by  this  plan,  one  of 
which  resulted  in  anchylosis,  but  the  other  was  much  more  successful. 
H.  Bond,  of  Philadelphia,  has  also  lately  contrived  a  very  ingenious 

Fig.  69. 


Bond's  elbow  splint. 


BASE    OF    THE    CONDYLES. 


251 


splint  for  the  elbow-joint,  and  which  is  designed  also  to  afford  a  cona- 
plete  support  to  the  forearm. 

For  myself,  I  generally  prefer  gutta  percha,  moulded  and  applied 
accurately  to  the  limb,  in  the  same  manner  as  I  have  already  directed 
in  fractures  of  the  surgical  neck  and  shaft  of  the  humerus,  except  that 
it  shall  be  extended  beyond  the  elbow  to  the  wrist,  so  as  to  support 
the  whole  length  of  the  arm,  elbow,  and  forearm.  Some  experience 
in  the  use  of  wooden  angular  splints  has  convinced  me  that  they  can- 
not be  very  well  fitted  to  the  many  inequalities  of  the  limb;  and  nei- 
ther pasteboard  nor  binder's  board  have  sufficient  firmness,  especially 
in  that  portion  which  covers  the 

joint.  Angular  splints,  furnished  Fig.  70. 

with  a  movable  joint,  possess 
the  advantage  of  enablinsr  us  to 
change  the  angle  of  the  limb  at 
pleasure,  and  of  keeping  up  some 
degree  of  motion  in  the  articula- 
tion without  disturbing  the  frac- 
ture or  removing  the  dressings; 
but  the  cross-bars  of  Days'  and 
Eose's  splints  render  them  com- 
plicated, and  are  in  the  way  of  a 
nice  application  of  the  rollers  ; 
while  they  are  all  equally  liable 
to  the  objection  stated  against 
angular  wooden  splints  without 
joints,  viz.,  that  they  seldom  can 
be  made  to  fit  accurately  the 
many  irregularities  of  the  arm, 
elbow,  and  forearm.  Welch's 
splints,  made  of  a  material  pos- 
sessing a  slight  amount  of  flexi- 
bility, approach  more  nearly  the 
accomplishment  of  these  indica- 
tions than  any  other  manufac- 
tured splint  with  which  I  am  acquainted,  but  the  number  of  cases  in 
practice  to  which  they  are  applicable  will  be  found  to  be  limited,  while 
gutta  percha  has  no  limit  in  its  application. 

Whatever  material  is  employed,  a  pretty  large  pledget  of  fine  cotton 
batting  ought  to  be  laid  in  front  of  the  elbow-joint,  to  prevent  the 
roller  from  excoriating  the  delicate  and  inflamed  skin,  and  great  care 
should  be  taken  to  protect  the  bony  eminences  about  the  joint,  or, 
rather,  to  relieve  them  from  pressure,  by  increasing  the  thickness  of 
the  pads  above  and  below  these  eminences. 

At  a  very  early  day,  so  early,  indeed,  as  the  seventh  or  eighth  day, 
the  splint  should  be  removed,  and,  while  the  fragments  are  steadied, 
gentle,  passive  motion  should  be  inflicted  upon  the  joint.  This  prac- 
tice should  be  repeated  as  often  as  every  second  or  third  day,  in  order 
to  prevent,  as  far  as  possible,  anchylosis.  If  much  swelling  follows 
the  injury,  it  is  my  custom  to  open  the  dressings,  without  removing 


The  author's  elbow  splint 


252  FEACTUEES    OF    THE    HUMEEUS. 

the  splints,  on  the  second  or  third  day  after  the  accident,  or  at  any 
time  when  the  symptoms  admonish  us  of  its  necessity.  Occasionally 
it  is  well  to  change  the  angle  of  the  splint  before  reapplying  it.  If 
the  angular  splint  with  a  movable  joint  is  used,  slight  changes  may  be 
made  while  the  splint  is  on  the  arm;  but  if  the  angle  is  much  changed 
without  removing  the  rollers,  they  become  unequally  tightened  over 
the  arm,  and  may  do  mischief. 

When  anchylosis  has  actually  taken  place,  we  may  more  or  less 
overcome  the  contraction  of  the  muscles  and  of  the  ligaments  by  pas- 
sive motion,  or  by  directing  the  patient  to  swing  a  dumb-bell  or  some 
heavy  weight  in  his  hands,  as  first  recommended  by  Hildanus. 


§  1.  Fracture  at  the  Base  of  the  Condyles,  complicated  with  Frac- 
ture BETWEEN  THE  CONDYLES,  EXTENDING  INTO  THE  JoiNT. 

This  fractare,  which  is  but  a  variety  or  complication  of  the  preceding 
fracture,  is  even  more  difficult  of  diagnosis;  and 
Fig-  VI.  its  signs,  results,  and  proper  treatment  differ 

sufficiently  to  demand  a  separate  consideration. 
I  have  recognized  the  accident  four  times. 
Confined  to  no  period  of  life,  it  seems  to  be  the 
result  of  a  severe  blow  inflicted  directly  upon 
the  lower  and  back  part  of  the  humerus,  or 
upon  the  olecranon  process.  Dr.  Parker,  of  New 
York,  was  inclined  to  regard  an  obscure  acci- 
dent about  the  elbow-joint,  which  he  saw  in  a 
lad  sixteen  years  old,  as  a  longitudinal  fracture 
of  the  humerus,  with  separation  of  one  condyle, 
but  which  had  been  occasioned  by  a  fall  upon 

Fracture  at  the  base  of,  and       J^^    haud.^        For    mySclf,    I    should    regard    this 

between  the  condyles.  latter   circumstaucc   as   prcsumptivc   evidence 

that  it  was  not  a  fracture  of  this  character,  yet 
I  do  not  mean  to  deny  the  possibility  of  its  occurrence  in  this  way. 

Its  characteristic  symptoms  are,  increased  breadth  of  the  lower  end 
of  the  humerus,  occasioned  by  a  separation  of  the  condyles ;  displace- 
ment upwards  and  backwards  of  the  radius  and  ulna ;  crepitus  and 
mobility  at  the  base  of  the  condyles,  with  crepitus  also  between  the 
condyles,  developed  by  pressing  the  condyles  together ;  or,  when  the 
radius  and  ulna  are  drawn  up,  by  restoring  these  bones  first  to  place 
by  extension,  and  then  pressing  upon  the  opposite  condyles ;  shorten- 
ing of  the  humerus. 

Its  consequences  are,  generally,  great  inflammation  about  the  joint, 
permanent  deformity  and  bony  anchylosis.  An  opposite  result  must 
be  regarded  as  fortunate,  and  as  an  exception  to  the  rule. 

Of  the  treatment,  we  can  only  say  that  it  must  be  chiefly  directed  to 
the  prevention  and  reduction  of  inflammation,  at  least  during  the  first 
few  days.     Nor  is  this  inconsistent  with  an  early  reduction  of  thefrag- 

'  Parker,  New  York  Journal  of  Medicine,  Nov.  1856,  p.  391,  3d  series,  vol.  i. 


FEACTUEE  AT  THE  BASE  OF  THE  CONDYLES.      253 

ments,  and  moderate  efforts,  by  splints  and  bandages,  such  as  we  have 
directed  in  case  of  a  simple  fracture  at  the  base  of  the  condyles,  to 
keep  the  fragments  in  place.  ISTo  surgeon  would  be  justified  in  refus- 
ing altogether  to  make  suitable  attempts  to  accomplish  these  important 
indications  ;  but  he  must  always  regard  them  as  secondary  when  com- 
pared with  the  importance  of  controlling  the  inflammation. 

When  splints  are  employed,  the  same  rules  will  be  applicable  both 
as  to  their  form  and  mode  of  application,  as  in  cases  of  simple  fracture 
above  the  condyles. 

The  following  examples  will  more  completely  illustrate  the  charac- 
ter, history,  and  proper  treatment  of  these  cases,  than  any  remarks  or 
rules  which  we  can  at  present  make : — 

A  woman,  living  in  this  city,  get.  44,  fell  upon  the  sidewalk  in  Janu- 
ary, 1850,  striking  upon  her  right  elbow.  I  saw  her  a  few  minutes 
after  the  accident,  but  the  parts  about  the  joint  were  already  consider- 
ably swollen,  and  it  was  not  without  difficulty  that  the  diagnosis  was 
made  out.  The  forearm  was  slightly  flexed  upon  the  arm,  and  proned. 
On  seizing  the  elbow  firmly,  a  distinct  motion  was  perceived  above  the 
condyles,  and  a  crepitus.  I  could  also  feel,  indistinctly,  the  point  of 
the  upper  fragment.  While  moderate  extension  was  made  upon  the 
arm,  the  condyles  were  pressed  together,  when  it  was  apparent  that 
they  had  been  separated.  On  removing  the  extension,  they  again 
separated,  and  the  olecranon  drew  up.  She  was  in  a  condition  of  ex- 
treme exhaustion,  and  the  bones  were  easily  placed  in  position. 

An  angular  splint  was  secured  to  the  limb,  and  every  care  used  to 
support  the  fragments  completely,  but  gently. 

From  this  date  until  the  conclusion  of  the  treatment,  the  dress- 
ings were  removed  often,  and  the  elbow  moved  as  much  as  it  was  pos- 
sible to  move  it. 

Seven  months  after  the  accident,  the  elbow  was  almost  completely 
anchylosed  at  a  right  angle.  The  fingers  and  wrist  also  were  quite 
rigid.  Six  years  later,  the  anchylosis  had  nearly  disappeared ;  she 
could  now  flex  and  extend  the  arm  almost  as  much  as  the  other;  the 
wrist-joint  was  free,  and  the  fingers  could  be  flexed,  but  not  sufficiently 
to  touch  the  palm  of  the  hand.  The  line  of  fracture  through  the  base 
could  be  traced  easily,  but  the  humerus  was  not  shortened.  There 
was,  moreover,  much  tenderness  over  the  point  of  fracture  through  the 
base,  and  at  other  points.  Occasionally,  a  slight  grating  was  noticed 
in  the  radio-humeral  articulation.  She  experienced  frequent  pains  in 
the  arm,  and  especially  along  the  back  and  radial  border  of  the  ring 
finger.  During  the  first  year  or  two  after  the  accident,  the  arm  perished 
very  much,  but  although  the  hand  remained  weak,  the  muscles  were 
now  well  developed. 

A  gentleman  was  struck  with  the  tongue  of  a  carriage  with  which 
a  couple  of  horses  were  running.  The  blow  was  received  directly 
upon  the  back  of  the  left  elbow.  Dr.  Sprague  and  myself  removed 
some  small  fragments  of  bone,  and  while  opening  the  wound  for  this 
purpose,  we  could  see  distinctly  the  line  of  fracture  extending  into  the 
joint  as  well  as  across  the  bone.     The  condyles  were  not  separated. 

The  subsequent  treatment  consisted  only  in  the  use  of  such  means 


254  FRACTURES    OF    THE    HUMERUS. 

as  would  best  support  the  limb,  and  most  successfully  combat  inflam- 
mation. The  arm  and  forearm  were  laid  upon  a  broad  and  well 
cushioned  angular  splint,  covered  with  oil-cloth,  to  which  they  were 
fastened  by  a  few  light  turns  of  a  roller. 

Twelve  years  after,  I  found  the  humerus  shortened  one  inch  and  a 
half.  During  the  first  year,  he  says,  there  was  no  motion  in  the  elbow- 
joint,  but  he  can  now  flex  and  extend  the  forearm  through  about  45°  ; 
when  flexed  to  a  right  angle,  it  seems  to  strike  a  solid  body  like  bone. 
Rotation  of  the  forearm  is  completely  lost,  the  hand  being  in  a  posi- 
tion midway  between  supination  and  pronation.  He  suffers  no  pain, 
and  his  arm  is  quite  strong  and  useful.  No  means  have  been  em- 
ployed to  restore  the  functions  of  the  limb  but  passive  motion  at  first, 
and  subsequently  constant,  active  use  of  the  hand  and  arm. 

The  late  Dr.  Thomas  Spencer,  of  Geneva,  used  to  relate  a  case  in 
which  a  surgeon  was  called  to  what  he  supposed  to  be  a  fracture  of  the 
lower  end  of  the  humerus,  and  which  he  treated  accordingly,  with . 
splints,  &c.  On  the  second  or  third  day,  another  surgeon  was  called, 
who  removed  the  splints  and  bandages,  and  pronounced  it  a  disloca- 
tion of  the  radius  and  ulna  backward ;  but  he  was  unable  to  reduce  it. 

After  some  time,  the  first  surgeon  was  prosecuted  for  having  treated 
as  a  fracture  what  proved  to  be  a  dislocation.  Dr.  Spencer,  who  had 
examined  the  arm  carefully,  gave  his  testimony  last,  and  at  a  time 
when,  from  the  evidence,  it  seemed  almost  certain  that  the  surgeon 
must  be  mulcted  in  heavy  damages ;  but  he  declared  his  belief  that 
both  surgeons  were  right,  since,  on  measuring  the  breadth  of  the 
hume'rus  through  its  two  condyles,  he  found  that  the  humerus  of  the 
injured  arm  was  three-quarters  of  an  inch  wider  than  the  opposite. 
His  conclusion,  therefore,  was  that  the  condyles  had  been  split  asunder 
and  were  now  separated ;  that  the  first  surgeon  properly  reduced  this 
fracture,  but  that  when,  on  the  second  or  third  day,  the  second  sur- 
geon removed  the  splints  and  the  dressings,  a  contraction  of  the  mus- 
cles had  taken  place  and  the  dislocation  occurred,  the  bones  of  the 
forearm  being  drawn  up  between  the  fragments.  Dr.  Spencer  believed 
this  was  an  example  of  the  variety  of  fracture  now  under  considera- 
tion, but  it  is  not  quite  certain  that  there  was  anything  more  than  an 
oblique  fracture  extending  into  the  joint,  followed  by  a  dislocation. 
In  either  case,  the  first  surgeon  was  entitled  to  an  acquittal,  and  so  the 
jury  promptly  declared  by  their  verdict. 

In  a  case  of  compound  comminuted  fracture  of  the  character  now 
under  consideration.  Dr.  Stone,  of  the  Bellevue  Hospital,  New  York, 
removed  the  condyles  and  sawed  off'  the  sharp  end  of  the  humerus. 
The  woman  was  twenty-six  years  old  and  intemperate.  The  operation 
was  made  as  a  substitute  for  amputation.  No  serious  complications 
followed.  On  the  ninety-sixth  day,  the  wounds  were  completely  healed, 
and  she  could  bend  the  forearm  to  a  right  angle  with  the  arm,  the 
action  of  the  muscles  having  drawn  up  the  radius  and  ulna  against 
the  lower  end  of  the  shaft  of  the  humerus,  so  that  the  motions  were 
natural  and  free.'     The  practice,  as  the  result  sufficiently  shows,  was 

•  Stone,  New  York  Journ.  of  Med.,  May,  1851,  p.  302,  vol.  vi.  2d  series. 


FEACTURES    OF    THE    INTERNAL    EPICONDYLE.  255 

eminently  judicious ;  and  its  practicability  ought  always  to  be  well 
considered  before  resorting  to  the  serious  mutilation  of  amputation. 
The  great  principle  upon  which  the  success  of  resection  is  here  based 
is  the  shortening  of  the  bone,  whereby  the  reduction  may  be  accom- 
plished without  painful  tension  to  the  muscles ;  a  principle  which  will 
demand  of  us  hereafter  a  more  careful  consideration  and  a  wider 
application. 

Fractures  of  the  Condyles. 

Chaussier  describes  that  portion  of  the  lower  end  of  the  humerus 
which  articulates  with  the  ulna  as  the  trochlea,  and  that  portion  which 
articulates  with  the  radius  as  the  condyle ;  naming  the  apophyses 
which  arise  from  them,  respectively,  epitrochlea  and  epicondyle.  Some 
of  the  French  writers  have  adopted  this  nomenclature,  but  I  prefer,  as 
being  more  familiar  to  my  own  countrymen,  the  terms  external  and 
*  internal  condyle,  to  which  it  will  be  convenient  to  add  the  terms 
external  epicondyle  and  internal  epicondyle,  as  indicating  the  extreme 
lateral  projections,  which  are  formed  from  separate  points  of  ossifica- 
tion, and  which  do  not  become  united  to  the  trochlea  until  about  the 
seventh  year  of  life,  and  sometimes  much  later. 

When,  therefore,  we  speak  of  a  fracture  of  the  epicondyle,  we  refer 
only  to  a  separation  of  the  epiphysis,  such  as  it  is  in  early  life ;  or  to 
its  true  fracture,  when,  at  a  later  period,  it  has  become  an  apophysis. 


§  8,  Fractures  of  the  Internal  Epicondyle  {Epitrochlea.     Chaussier.) 

.This  is  the  fracture  which  Granger  first  described  in  the  Edinburgh 
Medical  and  Surgical  Joimial,^  and  which  he  ascribed  solely  to  muscu- 
lar action.     "A  distinguishing  circumstance  attending  this  fracture  is 
that  of  its  being  occasioned  by  sudden  and  violent 
muscular  exertion ;  and  it  will  be  recollected  that  ^ig-  72. 

from  the  inner  condyle  those  powerful  muscles  which 
constitute  the  bulk  of  the  fleshy  substance  of  the 
ulnar  aspect  of  the  forearm  have  their  principal 
origin.  The  way  in  which  the  muscles  of  the  inner 
condyle  are  involuntarily  thrown  into  such  sudden 
and  excessive  action  I  take  to  be  this :  the  endeavor 
to  prevent  a  fall  by  stretching  out  the  arm,  and  thus 
receiving  the  percussion  from  the  weight  of  the  body  on  the  hand."^ 

It  is  a  fact,  perhaps  of  some  significance  in  this  connection,  that 
most  of  these  fractures  occur  in  children,  before  the  union  of  the  epi- 
physis is  completed,  when  muscular  contraction  might  more  often 
prove  adequate  to  its  separation,  and  when  the  epicondyle  is  less 
prominent,  and,  therefore,  less  exposed  to  direct  blows  than  in  adult 
life ;  thus,  of  five  fractures  which  I  have  distinctly  recognized  as  frac- 

1  "On  a  Particular  Fracture  of  tlie  Inner  Condyle  of  tlie  Humerus,"  by  Benjamin 
Granger.  Surgeon,  Burtou-upon-Trent.     Op.  cit.,  vol.  xiv.  pp.  196-201,  April,  1818. 

2  Ibid.,  p.  196. 


256  FKACTURES    OF    THE    HUMERUS. 

tures  of  the  epicondyle,  all,  except  one,  occurred  between  the  ages  of 
two  and  fifteen  years.  But  then  it  is  equally  true  that  a  large  majority 
of  all  the  fractures  of  the  internal  condyle,  including  those  which  enter 
the  articulation,  as  well  as  those  which  do  not,  belong  to  childhood 
and  youth.  I  have  seen  but  one  exception  in  fourteen  cases.  Since, 
then,  direct  blows  generally  produce  those  fractures  which  penetrate 
the  joint,  no  good  reason  can  be  shown  why  they  should  not  produce 
fractures  of  the  epicondyle.  The  exception  to  which  I  have  referred 
as  not  having  occurred  in  early  life,  is  sufficiently  rare  to  entitle  it  to 
especial  notice. 

On  the  16th  of  May,  1856,  a  laborer,  thirty-four  years  of  age,  fell 
from  an  awning  upon  the  side-walk,  dislocating  the  radius  and  ulna 
backwards;  the  dislocation  was  immediately  reduced  by  a  woman  who 
came  to  his  assistance,  but  when  he  called  on  me,  soon  after,  I  found 
a  small  fragment  of  the  inner  cond3de,  probably  the  epicondyle  alone, 
broken  off  and  quite  movable  under  the  finger.  It  was  slightly  dis- 
placed in  the  direction  of  the  hand. 

I  could  not  learn  positively  whether  in  falling  he  struck  the  elbow 
or  the  hand,  but  there  was  presumptive  evidence  that  he  struck  the 
hand;  if  so,  then  probably  the  fracture  was  the  result  of  muscular 
action,  which  is  the  more  extraordinary  as  having  taken  place  in  a 
man  of  his  age. 

It  is  pretty  certain,  however,  that  the  theory  of  causation  adopted 
by  Granger  is  too  exclusive.  A  lad  was  brought  to  me  in  October, 
1848,  aged  eleven,  who  had  just  fallen  upon  his  elbow,  the  blow  having 
been  "received,  as  he  aflSrmed,  and  as  the  ecchymosis  showed  pretty 
conclusively,  directly  upon  the  inner  condyle.  The  fragment  was 
quite  loose,  and  crepitus  was  distinct.  He  could  flex  and  extend  the 
arm,  and  rotate  the  forearm,  without  pain  or  inconvenience.  I  am 
quite  sure  the  fracture  did  not  extend  into  the  joint ;  the  result  seemed 
also  to  confirm  this  opinion,  for  in  three  months  from  the  time  of  the 
accident  the  motions  of  the  elbow-joint  were  almost  completely  re- 
stored. 

Indeed,  Mr.  Granger  has  failed  to  establish,  by  any  particular  proofs, 
that  in  more  than  one  or  two  of  his  cases  the  fracture  was  the  result 
of  muscular  action ;  but,  on  the  contrary,  I  am  disposed  to  infer,  from 
the  violent  inflammation  which  generally  ensued  in  his  cases,  from 
the  frequency  of  ecchymosis,  and  especially  from  the  injury  done  to 
the  ulnar  nerve  in  at  least  three  instances,  that  most  of  them  were 
produced  by  direct  blows  inflicted  from  below  in  the  fall  upon  the 
ground.  Fractures  produced  by  muscular  action  are  seldom  accom- 
panied with  much  inflammation  or  effusion  of  blood,  and  it  is  much 
more  probable  that  the  ulnar  nerve  should  have  been  maimed  by  the 
direct  blow  which  caused  the  fracture,  than  by  the  displacement  of  the 
apophysis,  which  is,  as  we  shall  presently  show,  almost  always  carried 
downwards,  and  oftener  slightly  forwards  than  backwards.  It  is  only 
when  the  fragment  is  forced  directly  backwards  that  the  ulnar  nerve 
could  be  made  to  suffer ;  a  direction  which,  it  does  not  seem  to  me,  it 
could  ever  take  from  muscular  action  alone. 


FEACTURES    OF    THE    INTERNAL    EPICONDYLE.  257 

Direciioyi  of  Displacement^  Symptoms^  &c. — I  have  seen  this  fragment 
displaced  in  the  direction  of  the  hand,  or  downwards,  very  manifestly, 
twice,  and  in  two  other  examples  a  careful  measurement  showed  a 
slight  displacement  in  the  same  direction.  The  greatest  displacement 
occurred  in  a  boy  fifteen  years  old,  who  was  brought  to  me  from  St. 
Catherines,  Canada  West.  He  had  fallen  upon  his  arm  in  wrestling, 
and  his  surgeon  found  a  dislocation  of  the  bones  of  the  elbow-joint, 
whicli  he  immediately  reduced.  The  fracture  was  not  at  that  time 
detected,  the  arm  being  greatly  swollen.  jSIo  splints  were  applied.  It 
was  three  months  after  the  accident  when  I  saw  him,  at  which  time  I 
found  the  internal  epicondyle  broken  off  and  removed  downwards  to- 
ward the  hand  one  inch  and  a  quarter;  and  at  this  point  it  had  become 
immovably  fixed.  Partial  anchylosis  existed  at  the  elbow-joint,  but 
pronation  and  supination  were  perfect. 

In  one  instance  I  believed  the  fragment  to  be  carried  about  three 
lines  upwards  and  two  backwards  toward  the  olecranon ;  in  each  of  the 
other  examples  the  fragment  has  not  seemed  to  suffer  any  sensible 
displacement. 

Granger  found,  also,  in  the  five  examples  whicli  came  under  his 
notice,  the  epicondyle  carried  toward  the  hand,  with  more  or  less 
variation  in  its  lateral  position,  so  that  while  in  some  instances  it 
touched  the  olecranon,  in  others  it  was  removed  an  inch  or  more  in 
the  opposite  direction. 

It  is  probable  that,  except  where  controlled  by  the  force  and  direc- 
tion of  the  blow,  or  by  some  complications  in  the  accident,  the  frag- 
ment, if  displaced  at  all,  always  moves  downwards  toward  the  hand, 
or  downwards  and  a  little  forwards  in  the  direction  of  the  action  of 
the  principal  muscles  which  arise  from  this  apophysis;  and  when  the 
fracture  or  separation  is  the  result  of  muscular  action  alone,  this  form 
of  displacement  seems  to  me  to  be  inevitable.  In  addition  to  the 
mobility,  crepitus,  and  generally  slight  displacement  of  the  fragment, 
which  are  the  principal  signs  of  this  fracture,  it  may  be  noticed  that 
there  is  usually  some  embarrassment  in  the  motions  of  the  elbow-joint, 
which  may  be  due  in  part  to  the  swelling,  and  in  part  to  the  detach- 
ment of  the  point  of  bone  from  and  around  which  most  of  the  pro- 
nators and  flexors  of  the  forearm  have  their  rise.  In  one  instance, 
already  quoted,  that  of  the  lad  aged  eleven  years,  who  broke  the 
epicondyle  from  a  direct  blow,  the  motions  of  pronation,  with  flexion, 
were  not  at  all  impaired,  neither  immediately  nor  at  any  subsequent 
period,  but  the  fragment  was  never  sensibly,  or  only  very  slightly 
displaced. 

Granger  has  recorded  another  class  of  symptoms,  to  which  I  have 
already  alluded,  his  explanation  of  which,  however,  I-am  not  prepared 
to  admit.  One  of  these  cases  he  describes  as  follows :  A  boy,  eight 
years  old,  fell  with  violence^  and  broke  off'  completely  the  whole  of 
the  inner  epicondyle  of  the  right  humerus.  The  lad  said  he  had 
fallen  on  his  hand.  The  fragment  was  displaced  toward  the  hand. 
Severe  inflammation  followed,  but  he  recovered  the  free  and  entire 
use  of  the  elbow-joint  in  less  than  three  months  after  the  accident. 
No  splints  or  bandages  were  ever  employed. 
17 


258  FRACTURES    OF    THE    HUMERUS. 

From  the  moment  of  the  accident,  the  little  finger,  the  inner  side  of 
the  ring  finger,  and  the  skin  on  the  ulnar  side  of  the  hand,  lost  all 
sensation.  The  abductor  minimi  digit!  and  two  contiguous  muscles  of 
the  little  finger  were  also  paralyzed.  This  condition  lasted  eight  or 
ten  years,  after  which  sensation  and  motion  were  gradually  restored 
to  these  parts.  As  a  consequence  of  this  paralyzed  condition  of  the 
ulnar  nerve,  also,  successive  crops  of  vesications,  about  the  size  of  a 
split  horse-bean,  commenced  to  form  on  the  little  finger  and  ulnar  edge 
of  the  hand  some  weeks  after  the  accident,  leaving  troublesome  ex- 
coriations. This  eruption  did  not  entirely  cease  for  two  or  three 
months. 

In  two  other  cases,  Mr,  Granger  remarks  that  he  has  found  "  the 
same  paralysis  of  the  small  muscles  of  the  little  finger,  the  same  loss 
of  feeling  in  the  integuments,  and  the  same  succession  of  crops  of  vesi- 
cles on  the  afi'ected  parts  of  the  hand,  as  is  described  to  have  occurred 
in  the  preceding  case," 

Without  intending  to  intimate  a  doubt  of  the  accuracy  of  Mr.  Gran- 
ger's statement,  that  such  phenomena  have  followed  in  three  cases  out 
of  the  five  which  he  has  seen,  I  must  express  my  belief  that  it  was 
only  a  remarkable  concurrence  of  circumstances,  since  the  same  phe- 
nomena have  never  been  seen  by  myself,  nor  do  I  know  that  they 
have  been  observed  by  any  other  surgeon. 

Results. — As  in  all  other  accidents  about  the  elbow-joint,  a  tem- 
porary rigidity  is  almost  inevitable.  The  mere  confinement  of  the 
arm  in  a  flexed  position  is  sufficient  to  determine  this  result  without 
the  interposition  of  a  fracture;  but  when  inflammation  occurs,  more  or 
less  contraction  of  the  tendons,  muscles,  &c.,  about  the  joint  must  en- 
sue. To  this  circumstance,  therefore,  added  to  the  confinement,  rather 
than  to  the  fracture,  will  be  due  the  anchylosis.  If  the  fragment  is 
not  displaced,  the  fracture  cannot  certainly  be  responsible  for  the  loss 
of  motion,  since  it  does  not  in  any  way  involve  the  joint ;  and  if  dis- 
placement exists,  its  ultimate  effect  in  diminishing  the  power  of  the 
muscles  which  arise  from  the  apophysis  must  be  only  trivial  and  scarcely 
appreciable.  We  might,  therefore  reasonably  conclude  that  where 
the  accident  has  been  properly  treated,  permanent  anchylosis  would 
be  the  exception  and  not  the  rule.  This  view  of  the  matter  seems  also 
to  be  sustained  by  the  recorded  results.  In  Granger's  cases,  the  full 
range  of  flexion  and  extension  of  the  forearm  has  been  finally  restored, 
or  with  so  trifling  an  exception  as  not  to  be  observable  without  close 
attention,  in  every  instance;  except  in  the  one  already  mentioned, 
which  was  originally  complicated  with  dislocation ;  and  even  in  this 
case  the  ultimate  maiming  was  inconsiderable,  Malgaigne,  who  says 
"it  ought  to  be  understood  that  in  this  accident  articular  rigidity  is 
almost  inevitable,"  seems  nevertheless  to  admit  the  justness  of  Gran- 
ger's observations  as  to  the  final  result,  if  the  proper  means  are  em- 
ployed to  prevent  it,  I  have  myself  found  only  once  any  considerable 
impairment  of  the  motions  of  the  joint  after  the  lapse  of  a  few  years. 

Treatment. — This  accident  does  not  constitute  an  exception  to  the 
rule  which  experience  has  established,  that  apophyseal  projections 
when  once  displaced  can  seldom  be  restored  completely  to  position  or 


FEACTUEES    OF    THE    EXTEENAL    EPICONDYLE.  259 

maintained  in  position,  until  a  bony  union  is  consummated.  Granger 
remarks:  "I  have  purposely  avoided  saying  one  word  about  replacing 
the  detached  condyle  (epicondyle),  and  for  these  reasons :  during  the 
state  of  tumefaction  of  the  limb,  no  means  could  be  adopted  for  con- 
fining the  retracted  condyle  in  its  place,  beyond  that  of  the  relaxation 
of  the  muscles ;  and  both  before  the  tumefaction  has  commenced,  and 
after  it  has  subsided,  all  endeavors  to  replace  the  condyle,  or  even  to 
change  the  position  of  it,  have  failed."  He  even  proceeds  so  far  as  to 
declare  that,  while  attention  ought  to  be  given  to  the  reduction  of  the 
inflammation  by  appropriate  means,  we  ought,  nevertheless,  to  instruct 
the  patient  to  flex  and  extend  the  arm  daily  from  the  moment  the  ac- 
cident occurs  until  the  cure  is  completed,  and  without  any  regard  to 
the  consolidation  of  the  fragment ;  "  the  exercise  of  the  joint  in  this 
manner  must  constitute  the  principal  occupation  of  the  patient  for 
several  weeks ;  and  should  it  be  remitted  during  the  formation  and 
consolidation  of  the  callus,  much  of  the  benefit  which  may  have  been 
derived  from  this  practice  will  be  lost,  and  will  with  difficulty  be  re- 
gained." 

With  only  slight  qualifications  I  would  adopt  the  advice  of  Mr. 
Granger.  The  limb  ought  always,  at  first,  to  be  placed  in  a  position 
of  demiflexion,  so  that  if  anchylosis  should  unfortunately  ensue,  it 
should  be  in  the  condition  which  would  render  it  most  serviceable, 
and  also  because  in  this  position  the  muscles  which  tend  to  displace 
the  fragment  would  be  most  completely  relaxed.  While  thus  placed 
an  attempt  ought  to  be  made,  by  seizing  the  apophysis,  to  restore  it 
to  position  ;  and  if  the  effort  succeeds,  as  it  certainly  is  not  very  likely 
to  do,  a  compress  and  roller  ought  to  be  so  applied  as  to  maintain  it  in 
position ;  provided,  always,  that  it  shall  not  be  found  necessary  to  ap- 
ply the  roller  so  tight  as  to  endanger  the  limb,  or  increase  the  inflam- 
mation. An  angular  splint  would  be  an  almost  indispensable  part  of 
the  appareil,  at  least  with  children,  where  this  indication  is  in  view. 
In  no  case,  however,  ought  more  than  seven  or  fourteen  days  to  elapse 
before  all  bandaging  and  splinting  should  be  abandoned,  and  careful, 
but  frequent  flexion  and  extension  be  substituted. 


§  9.  Fractures  op  the  External  Epicondyle.    {Epicondyle,  Chaussier.) 

I  have  only  mentioned  this  supposed  fracture,  of  which  some  writers 
have  spoken  as  a  fact,  in  order  that  I  may  declare  my  conviction  that 
its  existence  has  never  been  made  out.  If  we  admit  the  possibility, 
that,  while  in  a  state  of  epiphysis,  it  might,  like  the  corresponding  in- 
ternal epiphysis,  be  separated  by  muscular  action,  we  must  yet  deny 
its  probability,  since  it  is  so  exceedingly  small ;  and  we  must,  for  the 
same  reason,  be  permitted  to  doubt  whether  the  fact  of  its  separation 
could  be  recognized  in  the  living  subject.  Moreover,  if  a  true  fracture 
occurs  at  this  point  as  the  result  of  external  violence,  it  is  sufficiently 
plain,  from  an  examination  of  the  anatomical  structure,  that  it  must 
more  or  less  extend  into  the  joint  and  involve  the  condyle  itself. 


260  FEACTUEES    OF   THE   HUMEEUS. 


§  10.  Practuees  op  the  Internal  Condyle.  (Trochlea,  Chaussier.) 

B.  Cooper,  South,  Sir  Astley  Cooper  and  others,  speak  of  fracture 
of  the  internal  condyle  as  very  common,  and  more  so  than  fracture 
of  the   external  condyle ;  while  Malgaigne,  who 
Fig-  73.  admits  its  existence,  has  never  met  with  a  single 

living  example,  and  regards  its  occurrence  as  ex- 
ceedingly rare.  In  a  record  of  fourteen  fractures 
I  have  found  no  difficulty  in  recognizing  four  as 
fractures  of  the  inner  condyle;  five,  I  have  already 
said,  were  fractures  of  the  epicondyle,  and  the  re- 
maining five  were  undetermined,  while  my  records 
furnish  fourteen  examples  of  undoubted  fractures  of 
the  external  condyle.  It  is  probable  that  Sir  Astley  did  not  intend 
to  make  any  distinction  between  fractures  of  the  condyle  and  epicon- 
dyle, and  this  might  explain  somewhat  his  opinion  of  the  relative  fre- 
quency of  these  accidents ;  but  even  rejecting  this  important  distinction, 
it  has  happened  to  me  to  see  just  as  many  examples  of  fracture  of  the 
outer  condyle  as  of  the  inner. 

Causes. — It  has  already  been  stated  that  fractures  of  the  internal 
condyle,  as  well  as  fractures  of  the  epicondyle,  belong  almost  exclu- 
sively to  infancy  and  childhood,  no  instance  having  come  under  my 
notice  after  the  eighteenth  year  of  life,  except  in  the  person  of  a  man 
thirty-four  years  old,  whose  case  I  have  mentioned  when  speaking  of 
fracture  of  the  epicondyle. 

I  have  seen  no  instance  which  could  be  traced  to  any  other  cause 
than  a  direct  blow,  such  as  a  fall  upon  the  elbow,  the  force  of  the  con- 
cussion being  received  directly  upon  the  condyle. 

Lonsdale  speaks  of  fractures  of  the  condyles  occasioned  by  falls 
upon  the  hands:  but  without  intending  to  question  their  possibility,  I 
will  state  frankly  that  they  seem  to  me  not  to  have  been  satisfactorily 
proven. 

Line  of  Fracture,  Displacement,  Sym'ptoms. — The  direction  of  the  line 
of  fracture  is  tolerably  uniform,  namely,  commencing  about  one  quarter 
or  half  an  inch  above  the  epicondyle,  it  extends  obliquely  outwards 
through  the  olecranon  and  coronoid  fossae,  and  enters  the  joint  through 
the  centre  of  the  trochlea. 

Displacement  of  the  lower  fragment  can  take  place  only  in  a  direc- 
tion upwards,  backwards,  forwards  and  inwards  (to  the  ulnar  side). 
The  fragment  cannot  be  carried  downwards,  in  the  direction  of  the 
hand,  nor  outwards,  in  the  direction  of  the  radius,  unless  the  radius 
also  is  broken  or  dislocated. 

The  most  common  form  of  displacement  is  upwards  and  backwards, 
and  perhaps  at  the  same  time  a  little  inwards;  the  ulna  remaining 
attached  to  the  lower  fragment,  and  following  its  movements.  I  have 
seen  one  instance  in  which  the  fragment  was  carried  directly  downwards 
toward  the  hand,  but  this  accident  was  originally  complicated  with  a 
dislocation  of  the  radius  backwards.  The  dislocation  was  immediately 
reduced.     Five  years  after,  when  the  young  man  was  twenty-three 


FEACTUKES    OF    THE    INTERNAL    CONDYLE.  261 

years  old,  I  found  the  condyle  displaced  downwards  and  forwards 
about  half  an  inch,  so  that  when  the  forearm  was  extended  it  became 
strikingly  deflected  to  the  radial  side. 

The  symptoms  which  characterize  this  fracture  are  crepitus,  almost 
always  easily  detected ;  mobility  of  the  fragment,  discovered  espe- 
cially by  seizing  upon  the  epicondyle,  or  by  flexing  and  extending  the 
arm  ;  displacement  of  the  smaller  fragment  and  a  projection  of  the 
olecranon  process,  this  latter  being  very  marked  when  the  forearm  is 
extended  upon  the  arm,  but  almost  completely  disappearing  when  the 
elbow  is  bent ;  projection  of  the  lower  end  of  the  humerus  in  front  when 
the  arm  is  extended  ;  the  humerus  shortened  when  measured  along  its 
ulnar  side,  from  the  internal  epicondyle ;  the  breadth  of  the  humerus, 
through  its  condyles,  generally  increased  slightly,  sometimes  half  an 
inch  or  more;  if  the  lesser  fragment  is  carried  upwards  it  will  also  be 
found  that  when  the  limb  is  extended,  the  forearm  will  be  deflected  to 
the  ulnar  side. 

Sir  Astley  Cooper  remarks  that  it  is  frequently  mistaken  for  a  dis- 
location ;  and  Thomas  M.  Markoe,  of  New  York,  has  shown  that  it  is, 
in  fact,  frequently  complicated  with  a  dislocation  of  the  head  of  the 
radius  backwards;  indeed,  he  expresses  a  belief  that  this  dislocation 
of  the  radius  seldom  or  never  occurs  without  a  fracture  of  the  internal 
condyle.'  I  shall  refer  to  his  views  again  when  considering  disloca- 
tions of  the  head  of  the  radius. 

Results. — It  is  probable  that  in  a  majority  of  cases  no  permanent 
displacement  exists;  although  the  irregularity  of  the  bony  deposits 
around  the  base  of  the  condyle,  which  generally  may  be  easily  felt, 
would  lead  to  a  contrary  opinion.  The  fact  that  the  lower  fragment 
usually  follows  the  motions  of  the  olecranon,  renders  its  replacement 
and  retention  comparatively  easy,  unless  some  complication  exists. 
It  is  not  from  displacement,  therefore,  so  much  as  from  permanent 
muscular,  and  especially  bony  anchylosis,  that  serious  maimings  so 
often  result.  Under  any  treatment  bony  anchylosis  will  very  often 
ensue,  and  under  improper  treatment  it  is  almost  inevitable. 

Treatment. — The  arm  must  be  immediately  flexed  to  nearly  or  quite 
a  right  angle,  when,  without  much  manipulation,  the  fragments  will 
be  made  to  resume  their  place.  A  gutta-percha,  right-angled  splint, 
such  as  I  have  already  directed  for  fractures  occurring  just  above  the 
condyles,  well  and  carefully  cushioned,  must  now  be  applied,  and 
secured  by  rollers.  Suitable  pads  must  also  aid  the  splint  and  roller, 
in  keeping  the  fragments  in  place.  Markoe  prefers  keeping  the  fore- 
arm in  a  position  about  ten  degrees  short  of  a  right  angle,  believing 
that  in  this  position  the  ulna  itself  will  act  as  a  splint,  and  by  its  sup- 
port on  the  uninjured  portion  of  the  trochlea,  hold  in  its  place  the 
broken  condyle.  Yery  properly,  also,  he  prefers  to  lay  the  angular 
splint,  made  of  tin  and  fitted  to  the  arm  and  forearm,  upon  the  back  of 
the  limb  instead  of  upon  the  front  or  sides.  If  it  is  upon  the  inside, 
it  covers  the  broken  condyle,  and  we  are  unable  to  know  so  well  its 
position ;  if  upon  either  side,  it  is  apt  to   press  injuriously  upon  the 

'  Markoe,  New  York  Journal  of  Medicine,  May,  1855,  p.  382,  second  series,  vol.  xiv. 


262  FRACTUEES    OF    THE    HUMERUS. 

epicondyles;  and  if  it  is  in  front,  the  fragments  cannot  be  so  well  ad- 
justed or  supported.  Upon  this  point,  however,  surgeons  are  not  very 
well  agreed,  and  no  doubt  more  will  depend  upon  the  care  with  which 
the  splint  is  applied  than  upon  the  surface  against  which  it  is  laid. 

Considerable  swelling  is  almost  certain  to  follow,  and  no  surgeon 
ought  to  hazard  the  chances  of  vesications,  ulcerations,  &c.,  by  neglect- 
ing to  open  or  completely  remove  the  dressings  every  day.  Within 
seven  days,  and  perhaps  earlier,  passive  motion  must  be  commenced, 
and  perseveringiy  employed  from  day  to  day  until  the  cure  is  accom- 
plished; indeed,  in  a  majority  of  cases  it  is  better  not  to  resume  the 
use  of  splints  after  this  period :  for  although  at  this  time  no  bony 
union  has  taken  place,  yet  the  effusions  have  somewhat  steadied  the 
fragments,  and  the  danger  of  displacement  is  lessened,  while  the  pre- 
vention of  anchylosis  demands  very  early  and  continued  motion. 

When  the  fracture  is  compound,  or  otherwise  complicated,  these 
simple  rules  will  seldom  be  found  applicable ;  indeed,  fractures  attended 
with  no  such  complications  will  occasionally  be  found  difficult  to  re- 
duce, or  to  maintain  in  position  after  reduction. 


§  11.  Fractures  of  the  External  Condyle. 

Causes. — All  of  the  fractures  (14)  which  I  have  seen  of  the  external 
condyle  occurred  in  children  under  thirteen  years  of  age,  except  one ; 
in  which  instance  a  woman,  eighty-eight  years  of  age,  fell  upon  her 
elbow  while  intoxicated,  breaking  off  the  outer  condyle.  Two  months 
after  the  accident  I  found  the  fragment  displaced  half  an  inch  upwards, 
and  firmly  united. 

In  a  large  majority  of  these  cases  the  patients  themselves  have 
affirmed,  and  the  surface  of  the  skin  has  furnished  conclusive  evidence, 
that  the  fracture  was  produced  by  a  direct  blow,  generally  by  a  fall 
upon  the  elbow. 

Line  of  Fracture,  Displacement,  and  Symptoms. — The  direction  of  the 
fracture  is  generally  such  that,  commencing  always  above  and  without 
the  capsule,  it  descends  obliquely  and  enters  the  joint  either  just  within 
or  through  the  "small  head"  or  articulating  surface  upon  which  the 
radius  is  received ;  or  else  it  penetrates  more  deeply  in  its  progress, 
and  passing  through  the  olecranon  fossa,  it  enters  the  joint  through 
the  middle  of  the  trochlea. 

In  the  first  of  these  classes  of  examples,  which  I  think  also  is  the 
most  common,  the  condyle  alone  is  broken  off,  and  it  is  liable  only  to 
become  displaced  backwards,  forwards,  or  outwards;  generally,  I  have 
found  it  displaced  a  little  outwards,  sufficiently  to  increase  manifestly 
the  breadth  of  the  condyles ;  or  it  has  been  carried  backwards ;  once 
slightly  forwards ;  it  is  also,  in  some  cases,  carried  upwards  in  a  small 
degree,  although  the  action  of  the  supinators  and  extensors  would 
seem  to  render  a  downward  displacement  more  common.  These  dis- 
placements are  usually  not  considerable,  and  in  a  few  cases  there  is 
none  at  all.  Whatever  may  be  the  direction  or  degree  in  which  the 
fragment  is  moved,  however,  the  head  of  the  radius  is  found  almost 


FEACTUEES    OF    THE    EXTEENAL    COKDYLE,  263 

always  to  accompany  it.     In  the  case  which  I  am  about  to  relate,  the 
head  of  the  radius  became  completely  separated  from  the  condyle. 

Frederick  Keaffer,  ^t.  11,  fell  from  a  load  of  hay,  and  he  is  confi- 
dent that  he  struck  the  ground  with  the  back  of  his  elbow.  Six  hours 
after  the  accident,  he  was  brought  to  me  by  the  physician  who  was 
first  called  to  him.  The  arm  was  much  swollen,  and  the  external  con- 
dyle could  not  be  distinctly  felt,  but  when  pressure  was  made  directly 
upon  it,  crepitus  and  motion  became  manifest.  The  head  of  the  radius 
was  at  the  same  time  dislocated  backwards,  and  separated  entirely  from 
the  condyle ;  its  smooth  button-like  head  being  very  prominent.  It  is 
diflficult  to  conceive  how  a  blow  from  behind  should  leave  the  head  of 
the  radius  dislocated  backwards,  or  how  the  radius  could  have  separated 
from  the  broken  condyle ;  but  as  the  examination  was  repeated  several 
times,  and  while  the  patient  was  under  the  influence  of  ether,  I  have 
no  doubt  of  the  fact.  Several  other  surgeons  who  were  present  con- 
curred with  me  in  opinion  fully. 

While  prosecuting  the  examination,  I  reduced  the  dislocation  of  the 
radius,  but  it  would  not  remain  in  place  a  moment  when  pressure  or 
support  was  removed.  The  lad  recovered  with  a  very  useful  arm,  the 
motions  of  flexion  and  extension,  with  pronation  and  supination,  after 
the  lapse  of  a  year,  being  nearly  as  complete  as  before  the  accident. 
The  radius  remains  unreduced. 

Sometimes  it  will  be  noticed  that  while  the  portion  of  the  condyle 
which  is  attached  to  the  radius  falls  backwards,  its  upper  and  broken 
extremity  pitches  forwards;  and  this  attitude  it  is  especially  prone  to 
assume  when  the  forearm  is  extended. 

It  is  even  possible,  when  the  fracture  traverses  the  trochlea,  for  the 
ulna  also  to  become  displaced  backwards  along  with  the  radius  and  the 
lesser  fragment. 

Crepitus,  which  is  usually  very  distinct,  is  most  easily  obtained  by 
rotating  the  radius,  or  by  seizing  upon  the  condyle  with  the  thumb 
and  fingers,  and  moving  it  backwards  and  forwards. 

Results. — Ordinarily,  this  fragment  unites  promptly  and  by  the 
interposition  of  a  bony  callus ;  but  in  a  few  cases,  I  have  noticed  that 
either  no  union  has  occurred,  or  the  union  has  been  accomplished 
only  through  the  medium  of  fibrous  structure,  and  the  fragment  con- 
tinued afterward  to  move  with  the  radius. 

As  a  consequence,  probably,  of  the  displacement  of  the  lesser  frag- 
ment upwards,  the  forearm,  when  straightened,  is  occasionally  found 
deflected  to  the  radial  side.  The  surgeon  must  not,  however,  confound 
the  deflection  which  is  natural,  and  which  is  greater  in  some  persons 
than  in  others,  with  the  unnatural  radial  inclination  which  is  occa- 
sioned sometimes  by  this  accident.  I  have  met  with  this  phenomenon 
three  times  in  children  under  three  years  of  age,  in  one  of  which  I 
could  not  discover  that  the  condyle  was  carried  toward  the  shoulder, 
but  only  outwards;  in  each  of  the  other  cases  the  fragment  had  united 
by  ligament.     The  following  is  one  of  the  examples  referred  to : — 

A  girl,  set.  3,  fell  and  broke  the  external  condyle  of  the  left  humerus ; 
fracture  extending  freely  into  the  joint;  crepitus  distinct;  forearm 
slightly  flexed ;  prone.   Lesser  fragment  displaced  outwards  and  a  little 


2fi4  FRACTUEES    OF    THE    HUMERUS. 

backwards,  carrying  with  it  the  radius.  On  the  second  day  I  was  dis- 
missed on  account  of  the  unfavorable  prognosis  which  I  gave,  or  rather 
because  I  refused  to  guarantee  a  perfect  limb,  and  an  empiric  was 
employed,  who  readily  gave  the  requisite  guarantee,  namely,  his  word 
of  honor. 

July  2,  1857,  several  months  after  the  accident,  the  father  brought 
her  to  me  for  examination.  There  was  no  anchylosis,  but  the  lesser 
fragment  had  never  united,  unless  by  ligament,  moving  freely  with 
the  head  of  the  radius.  When  the  forearm  was  straightened  upon 
the  arm  it  fell  strongly  to  the  radial  side,  but  resumed  its  natural 
relation  again  when  the  elbow  was  flexed. 

The  two  other  examples  are  reported  at  length  in  the  second  part 
of  my  Report  on  Deformities  after  Fractures  as  Cases  57  and  59  of  frac- 
tures of  the  humerus. 

In  one  other  example,  however,  mentioned  also  in  my  report  as 
Case  56,  the  deflection  was  to  the  opposite  side.  I  examined  the  lad 
one  year  after  the  accident,  he  being  then  five  years  old,  and  I  found 
the  external  condyle  very  prominent  and  firmly  united,  but  not  appa- 
rently displaced  in  any  direction  except  outwards.  The  radius  and 
ulna  had  evidently  suffered  a  diastasis  at  their  upper  ends,  but  all  of 
the  motions  of  the  joint  were  free  and  perfect. 

Dorsey^  speaks  of  this  lateral  inclination  as  being  always  to  the 
ulnar  side,  but  does  not  indicate  to  what  particular  fracture  of  the 
elbow  it  belongs.  He  has  also  described  a  splint,  contrived  by  Dr. 
Physick,  intended  to  remedy  the  deformity  in  question. 

Chelius  also  speaks  of  the  same  deformity  as  occurring  after  frac- 
tures of  the  internal,  but  does  not  mention  it  in  connection  with  frac- 
tures of  the  external  condyle,  that  is,  an  inclination  of  the  forearm  to 
the  ulnar  side. 

In  more  than  half  of  the  cases  of  fracture  of  this  condyle  some 
degree  of  anchylosis  has  resulted,  lasting  at  least  several  months.  I 
have  seen  it  remaining  after  a  lapse  of  from  one  to  twenty  years,  but 
generally  it  gradually  diminishes,  and,  in  a  majority  of  cases,  com- 
pletely disappears  after  a  few  years. 

TreatDient. — I  do  not  know  that  I  need  add  much  to  what  has 
already  been  said  in  relation  to  the  treatment  of  fractures  of  the 
opposite  condyle,  and  at  the  base  of  the  condyles,  since  the  measures 
applicable  to  the  one  are,  in  general,  applicable  to  the  other. 

Generally,  the  forearm  ought  to  be  flexed  upon  the  arm,  especially 
with  a  view  to  overcome  the  usual  tendency  in  the  upper  end  of  the 
lower  fragment  to  pitch  forwards,  and  which  form  of  displacement  is 
greatly  increased  by  straightening  the  arm.  A  remarkable  exception 
to  this  rule,  and  the  only  one  I  have  seen,  must  be  mentioned. 

James  Cronyn,  aged  six,  was  brought  to  me  in  March,  1857,  having, 
a  few  minutes  before,  fallen  from  a  height  of  four  or  five  feet  to  the 
ground.  His  father  said  the  elbow  had  been  broken  at  the  same  point 
two  years  before,  and  from  that  time  had  remained  stiff  and  crooked. 
I  found  the  external  condyle  broken  off,  and,  with  the  head  of  the 

1  Elements  of  Surgery,  by  Philip  Syng  Dorsey,  Phila.  ed.,  1813,  vol.  i.  p.  146. 


FRACTURES    OF    THE    EXTERNAL    CONDYLE.  265 

radius,  carried  backwards.  This  was  the  position  which  it  occupied 
constantly,  though  it  was  easily  restored  and  maintained  in  position 
when  the  arm  was  straight,  but  not  by  any  possible  means  when  the 
elbow  was  flexed.  I  dressed  the  arm,  therefore,  in  an  extended  posi- 
tion, with  a  long  felt  splint,  and  the  fragments  remained  well  in  place 
until  a  cure  was  accomplished. 

In  certain  examples,  I  have  no  doubt  also  that  advantage  might  be 
derived  from  the  use  of  Physick's  splint,  intended  to  obviate  the  out- 
ward or  inward  inclination  of  the  forearm. 

Fig.  74. 


Physick's  splint. 

It  is  especially  deserving  of  notice  that,  in  the  three  cases  in  which 
I  have  observed  bony  union  to  fail,  and  the  fragments  to  continue 
movable,  the  motions  of  the  elbow-joint  have,  in  a  very  short  time, 
been  completely  restored.  If  it  does  not  prove  that  Granger  was 
correct  in  his  views  as  applied  to  fractures  of  the  internal  epicondyle, 
namely,  that  it  was  of  little  or  no  consequence  whether  the  fragment 
united  or  not,  and  that  the  elbow-joint  ought  to  be  submitted  to  free 
motion  from  the  beginning  to  the  end  of  the  treatment — if  it  does  not 
absolutely  prove,  I  say,  the  correctness  of  his  views,  it  at  least  must 
abate  our  apprehensions  of  the  supposed  evil  results  of  non-union  in 
the  case  of  the  fracture  now  under  consideration. 

I  shall  take  the  liberty  of  quoting  also,  with  a  qualified  approval, 
the  opinion  of  Dr.  John  C.  "Warren,  of  Boston,  as  stated  by  Dr.  Norris 
in  his  Report  on  Surgery^  made  to  the  American  Medical  Association 
in  1848. 

"In  the  treatment  of  fractures  of  the  condyles  of  the  os  humeri,  a 
course  is  usually  recommended  which  he  believes  to  be  hurtful,  inas- 
much as  it  favors  the  worst  consequences  of  the  injury,  namely,  loss 
of  motion  in  the  joint.  By  this  mode  of  treatment,  the  fractured  piece 
becomes  sufSciently  fixed  to  create  partial  anchylosis ;  and  there  is  so 
much  pain  afterwards  in  the  proposed  passive  movements  as  to  cause 
the  omission  of  these  measures  until  permanent  stiffness  takes  place. 
The  proper  course  in  the  management  of  these  accidents  he  conceives 
to  be,  1st.  To  apply  no  splints,  but  in  the  earlier  days  to  make  use  of 
the  proper  means  to  prevent  inflammation.  2d.  To  accustom  the 
patient  to  early  and  daily  movements  of  flexion  and  extension.  3d. 
When  the  action  of  the  joint  becomes  limited,  to  overcome  the  resist- 
ance by  force,  and  repeat  it  daily,  until  the  tendency  of  the  joint  to 
stiffen  ceases. 


266  FRACTURES    OF    THE    RADIUS. 

"The  accomplishment  of  this  process,  he  adds,  is  so  verj  painful 
that  few  patients  have  courage  to  submit  to  it,  and  few  surgeons  firm- 
ness to  prosecute  it.  The  consequence  has  been  that  in  a  great  num- 
ber of  cases  the  use  of  the  articulation  to  a  greater  or  less  extent  has 
been  lost.  The  introduction  of  etherization,  by  preventing  the  pain, 
gives  us,  in  the  opinion  of  Dr.  Warren,  the  means  of  overcoming  the 
resistance.  By  its  aid  he  has  restored  the  motion  of  a  considerable 
number  of  anchylosed  elbows,  and  has  successfully  applied  the  same 
measures  to  other  joints,  particularly  to  the  shoulder  and  knee.  This 
has  now  become  his  settled  practice,  with  the  results  of  which  he  is 
entirely  satisfied.  The  inflammation  consequent  upon  the  forced 
movements  of  an  anchylosed  joint  is  not  to  be  lost  sight  of.  By  a 
reasonable  abstraction  of  blood,  and  other  anti-inflammatory  treat- 
ment, he  has  never  found  it  alarming."^ 

My  respect  for  the  distinguished  surgeon  whose  opinion  is  here 
given  does  not  permit  me  to  question  the  correctness  of  his  practice ; 
but  I  cannot  avoid  a  belief  that  his  language  does  not  convey  a  precise 
idea  of  his  views.  If  he  intends  to  say  that  he  would  move  the  joint 
freely  when  it  is  suffering  from  acute  inflammation,  and  when  motion 
occasions  great  pain,  I  must  protest  against  the  practice  as  likely  to 
do  vastly  more  harm  than  good  in  any  case ;  but  if  he  would  move  the 
joint  from  the  first  when  the  inflammation  and  swelling  are  trivial, 
and  "wlien  it  occasions  only  an  endurable  amount  of  pain,  then  his 
views  are  just  and  his  practice  worthy  of  imitation. 


CHAPTEH    XXI. 

FRACTURES   OF  THE  RADIUS. 

Of  sixty-one  fractures  of  the  radius  which  have  come  under  my  ob- 
servation, three  belonged  to  the  upper  third,  two  to  the  middle  third, 
and  fifty-six  to  the  lower  third.  Two  were  compound,  and  fifty-nine 
simple.  Thirty-nine  are  recorded  of  males,  and  twenty  one  of  females ; 
twenty-seven  as  having  occurred  in  the  left  arm,  and  sixteen  in  the 
right. 

Fracture  of  the  neck  of  .the  radius,  as  a  simple  accident,  uncompli- 
cated with  any  other  fracture  or  dislocation,  is  exceedingly  rare ;  yet, 
owing  to  the  depth  of  the  superincumbent  mass  of  muscles,  and  the 
difficulty  of  determining,  where  so  many  bones  and  processes  approach 
each  other,  precisely  from  what  point  the  crepitus,  if  any  is  found, 
proceeds,  surgeons  have  often  been  deceived,  and  they  believed  that 
they  were  the  fortunate  possessors  of  this  rare  pathological  treasure, 

1  Transactions  of  the  American  Medical  Association,  vol.  i.  p.  174. 


FKACTUEES  OF  THE  NECK  OF  THE  RADIUS. 


267 


^^ 


when  the  autopsy  has  too  soon  disclosed  their  error.  Both  B.  Cooper 
and  Eobert  Smith  have  alluded  to  this  difficulty,  and  the  case  reported 
by  Dr.  Markoe  to  the  New  York  Pathological  Society,  and  published 
in  the  April  number  of  the  American  Medical  Monthly^  will  serve  to 
illustrate  the  same  point;  in  whicli  case  tbe  signs  of  a  fracture  of  the 
radius  at  its  neck  were  such  as  to  deceive  that  experienced  surgeon, 
yet  the  aatopsy  disclosed  the  fact  tkat  it  was  a  dislocation  of  the  head 
of  the  radius  forwards,  with  a  fracture  of  the  ulna.  Indeed,  its  exist- 
ence as  a  form  of  fracture  was  doubted  by  Sir  Astley  Cooper,  and  by 
others  has  been  actually  denied.  I  have  seen  no  specimen  obtained 
from  the  cadaver,  except  the  doubtful  one  contained  in  Dr.  Watts' 
cabinet,  and  of  which  I  have  furnished  an 
account,  accompanied  with  a  drawing,  in  my 
report  to  the  American  Medical  Association,^ 
and  the  specimen  owned  by  Dr.  Miitter,  of 
Philadelphia,  of  which  he  has  kindly  fur- 
nished me  the  following  description:  "His- 
tory unknown.  The  line  of  fracture  seems 
to  bave  passed  through  the  neck  of  the  left 
radius,  just  at  the  upper  extremity  of  the  bi- 
cipital protuberance.  Union  with  deformity 
has  resulted.  Owing  to  the  fracture  having 
taken  place  within  the  insertion  of  the  biceps, 
that  muscle  appears  to  have  drawn  forward 
and  upward  the  lower  end  of  the  short  upper 
fragment.  In  consequence  of  this  movement, 
the  articulating  facet  of  the  head  of  the  ra- 
dius is  tilted  backwards,  so  as  no  longer  to  be 
in  contact  with  the  humerus.  As  a  second- 
ary consequence,  the  anterior  edge  of  the 
head  of  the  radius  rests  permanently  against 
the  articulating  surface  of  the  humerus.  At 
this  new  point  of  contact  a  new  surface  of  ar- 
ticulation is  seen  to  have  been  formed,  while 
the  original  articulating  facet  is  directed 
backwards,  and  lies  at  right  angles  to  the 
one  of  more  recent  formation.  At  the  inner 
edge  of  the  new  articulation  of  the  head  of 
the  radius  with  the  humerus,  contact  with 
the  ulna  has  developed  another  surface  of 
articulation.  The  upper  and  lower  fragments  are  united  at  an  angle, 
and  the  radius  does  not  appear  to  have  lost  in  length." 

Yelpeau  has  once  demonstrated  the  existence  of  this  fracture  in  a 
dissection,  but  the  fracture  was  accompanied  with  a  fracture  also  of 
the  coronoid  process ;  and  Berard  obtained  possession  of  a  similar 
specimen.  I  do  not  remember  to  have  seen  a  notice  of  any  others. 
Malgaigne  affirms,  with  his  usual  frankness,  that  although  he  has  occa- 
sionally believed  that  he  had  met  with  it,  the  autopsy,  whenever  it  has 


Fracture  of  neck  of  radius,  piiit- 
ters  cabinet.)  a.  Original  articu- 
lating facet.  6, 6.  Xew  articulating 
facets,     c.  Projecting  fragments. 


'  Transactions,  vol.  ix.  pp.  15"  and  229. 


268  FRACTUEES  OF  THE  RADIUS. 

been  obtained,  has  sbown  that  it  was  rather  a  subluxation  than  a  frac- 
ture. On  the  other  hand,  Mr.  Soath  calls  it  a  "not  unfrequent  acci- 
dent," but  in  confirmation  of  this  declaration  he  cites  no  examples. 

While,  therefore,  the  presence  of  what  appear  to  be  the  rational 
diagnostic  signs  has  compelled  rae  to  record  one  case  as  an  uncompli- 
cated fracture  of  the  neck  of  the  radius,  and  two  others  as  fractures  at 
this  point  accompanied  either  with  a  fracture  of  the  humerus  or  a  dis- 
location of  the  ulna,  I  am  prepared  to  admit  that  some  doubt  remains 
in  my  own  mind  as  to  whether  in  either  case  the  fact  was  clearly  ascer- 
tained ;  nor  do  I  think,  speaking  only  of  the  simple  fracture,  that  it  will 
ever  be  safe  to  declare  positively  that  we  have  before  us  this  accident, 
lest,  as  has  happened  many  times  before,  in  the  final  appeal  to  that 
court  whose  judgment  waits  until  after  death,  our  decisions  should  be 
reversed. 

Nothing,  perhaps,  could  more  fully  illustrate  the  difficulty  of  diag- 
nosis in  the  case  of  injuries  received  in  the  neighborhood  of  the  head 
of  the  radius  than  the  testimony  given  in  the  case  of  Noyes  vs.  Allen, 
tried  in  the  Supreme  Court  at  Cambridge,  January,  1856,  before  Judge 
Bigelow.  Mr.  Noyes  injured  his  elbow,  January  7,  1854,  and  Dr. 
Allen,  who  was  called  immediately,  believed  that  the  ligaments  of  the 
joint  had  been  torn,  but  that  no  bones  were  broken  or  displaced.  On 
the  following  morning  he  was  dismissed,  and  Mr.  Noyes  went  home. 
Three  weeks  later  it  was  seen  by  Dr.  Dow,  who  also  thought  there  was 
no  fracture.  About  eight  weeks  after  the  accident  a  physician  exa- 
mined the  arm,  and  declared  the  neck  of  the  radius  broken  and  the 
fragments  displaced ;  and  when  the  case  was  finally  brought  to  trial, 
he  testified  still  that  such  was  certainly  the  fact:  and  five  other  physi- 
cians, not  one  of  whom,  however,  we  are  told,  was  a  member  of  the 
State  Medical  Society,  testified  positively  that  the  radius  was  broken 
at  its  neck,  producing  a  bony  protuberance;  that  such  an  injury  only 
could  account  for  the  symptoms  manifested  at  the  time  of  the  accident, 
and  that  no  other  fractures  or  injuries  of  the  joint  could  explain  so 
well  the  present  appearances  of  the  arm.  While,  on  the  part  of  the 
defence,  six  of  the  most  intelligent  medical  gentlemen  of  the  State, 
Drs.  Kimbal  and  Huntington,  of  Lowell,  and  Drs.  Townsend,  Lewis, 
Clark,  and  Gay,  of  Boston,  testified  that  the  head  and  neck  of  the 
radius  were  not  displaced,  nor  was  there  any  evidence  that  this  bone 
had  ever  been  broken.  There  is  every  reason  to  believe  that  these 
latter  gentlemen  were  correct;  yet  it  is  to  be  presumed  that  the  gen- 
tlemen who  first  testified  were  not  without  some  grounds  for  their 
opinions,  so  confidently  expressed. 

The  case  was  given  to  the  jury  after  a  trial  of  five  days,  who 
promptly  returned  a  verdict  for  the  defendant.^ 

Wlien  this  fracture  occurs,  the  upper  end  of  the  lower  fragment  will 
probably  be  carried  forwards  by  the  action  of  that  portion  of  the 
biceps  which  has  its  insertion  into  the  tubercle;  and  the  displacement 
in  this  direction  must  necessarily  be  increased  in  proportion  as  the 
arm  is  straightened.    In  the  cabinet  specimen  belonging  to  Dr.  Miitter, 

'  Amer.  Med.  Gazette,  vol.  vii.  p.  299. 


FRACTURES    OF    THE    HEAD    OF    THE    RADIUS.  269 

the  line  of  fracture,  commencing  in  the  neck,  has  terminated  in  the 
tubercle;  consequently  the  biceps,  having  still  some  attachment  to 
the  upper  fragment  as  well  as  the  lower,  has  drawn  them  both  for- 
wards. 

The  same  anterior  displacement  I  have  noticed  in  all  of  the  sup- 
posed living  examples,  but  whether  both  fragments  or  only  one  had 
suffered  displacement  I  am  unable  to  say. 

A  girl,  set.  11,  living  in  Ontario  Co.,  N.  Y.,  fell  from  a  tree  and  in- 
jured her  right  arm.  Her  surgeon,  who  regarded  it  as  a  fracture  of 
the  neck  of  the  radius,  reduced  the  fragments,  and  placed  the  forearm 
at  a  right  angle  with  the  arm.  On  the  twenty-eighth  day,  all  dress- 
ings were  removed,  and  the  patient  was  dismissed;  the  fragments 
seemed  to  be  in  place.  The  parents,  finding  the  elbow  stiff,  now  made 
violent  and  successful  efforts  to  straighten  the  arm. 

Fifteen  months  after  the  accident,  the  child  was  brought  to  me. 
There  was  at  this  time  a  bony  projection  in  front,  opposite  the  neck 
of  the  radius,  which  I  believed  to  be  the  point  of  fracture.  The  hand 
was  forcibly  proned,  and  she  had  only  a  limited  amount  of  motion  at 
the  elbow-joint.  The  anchylosis  was  probably  due  to  inflammation 
directly  resulting  from  the  severe  contusion ;  but  it  is  quite  probable 
that  the  forward  displacement  of  the  fragments  was  alone  due  to  the 
too  early  and  too  violent  attempts  to  straighten  the  arm ;  at  least,  this 
was  the  explanation  which  I  ventured  to  give  to  the  parents  at  the 
time. 

The  second  case  occurred  in  a  lad  eight  years  old,  living  in  Wyoming 
Co.,  N.  Y.  His  parents  brought  him  to  m.e  ten  weeks  after  the  injury 
was  received,  and  I  then  found  the  forearm  bent  to  a  right  angle  with 
the  arm,  and  anchylosed  at  the  elbow-joint.  The  hand  was  also 
forcibly  proned,  and  could  not  be  supined.  In  front,  and  opposite  the 
neck  of  the  radius,  there  was  a  distinct  bony  projection,  which  I  be- 
lieved to  be  the  point  of  union  of  the  broken  fragments.  The  external 
condyle  seemed  also  to  have  been  broken. 

The  third  example,  treated  originally  by  Dr.  Nott,  of  Buffalo,  was 
seen  by  me  six  mouths  after  the  accident.  The  upper  end  of  the  lower 
fragment  seemed  to  be  displaced  forwards.  There  was  very  little 
motion  at  the  elbow-joint,  and  both  pronation  and  supination  were 
completely  lost. 

I  have  seen,  in  Dr.  Miitter's  cabinet,  two  specimens  of  fracture  of 
the  outer  half  of  the  head  of  the  radius.  In  one  case,  the  small  frag- 
ment is  slightly  displaced  downwards  in  the  direction  of  the  axis  of 
the  bone;  and,  in  the  other,  the  fragment  is  thrown  outwards,  or  to 
the  radial  side.     Both  are  firmly  united  in  their  new  positions. 

In  the  treatment  of  fractures  of  the  neck  of  the  radius,  we  must  not 
neglect  to  flex  the  forearm  upon  the  arm,  so  as  to  relax,  as  completely 
as  possible,  the  biceps,  whose  advantageous  insertion  into  the  tubercle 
of  the  radius  would  be  certain  to  produce  displacement,  unless  this 
position  was  adopted.  A  single  dorsal  splint,  properly  padded,  should 
support  the  forearm,  while  the  surgeon,  having  placed  a  compress  over 
the  upper  end  of  the  lower  fragment,  proceeds  to  secure  the  whole 
with  a  roller. 


270  FRACTURES    OP   THE    RADIUS. 

Especial  care  must  also  be  taken  to  prevent  the  forearm  from  being 
extended  before  the  bony  union  is  fairly  consummated,  lest  the  biceps, 
now  firmly  contracted,  should  draw  the  lower  fragment  forwards,  as 
it  must  inevitably  do  while  the  bony  union  is  imperfect;  an  accident 
which,  there  is  some  reason  to  believe,  occurred  in  one  of  the  examples 
which  I  have  already  cited. 

If  the  patient  be  a  child,  or  if  there  is  any  reason  to  suppose  that 
these  rules  will  not  be  faithfully  complied  with,  it  would  be  well  to 
secure  the  arm  in  this  position  with  a  right-angled  splint. 

When  the  fracture  occurs  in  any  portion  of  the  radius  below  the 
insertion  of  the  biceps  and  above  the  insertion  of  the  pronator  radii 
teres,  Mr.  Lonsdale  suggests  the  propriety  of  placing  the  forearm  in  a 
condition  of  supination,  at  least  so  far  as  is  practicable,  for  the  purpose 
of  securing  a  proper  apposition  of  the  fragments.  His  argument  in 
favor  of  this  practice  is  ingenious,  and  deserves  consideration. 

When  the.  bone  is  broken  anywhere  in  this  portion,  the  action  of 
the  pronators  upon  the  upper  fragment  ceases  ;  while  that  of  the  biceps, 
which  is  a  powerful  supinator,  continues;  consequently  the  upper  frag- 
ment becomes  at  once,  and  completely,  rotated  outwards  or  supined. 
Now,  if  the  hand,  to  which  the  lower  end  of  the  radius  alone  remains 
attached,  should  be  forcibly  proned,  the  radius  will  also  be  rotated 
inwards  upon  its  own  axis ;  and  although  it  might  be  possible  in  this 
condition  to  bring  the  broken  ends  into  contact,  and  a  bony  union, 
without  deformity  might  be  consummated,  yet  the  power  of  supi- 
nation must  be  forever  lost;  since  the  union  has  been  effected  while 
the  head  and  upper  fragment  are  already  in  a  state  of  complete  supi- 
nation, and  if  such  is  the  fact  it  is  evident  that  the  whole  bone,  to- 
gether with  the  hand,  will  be  incapable  of  any  further  supination. 

It  is  not,  indeed,  the  practice  with  any  surgeons,  so  far  as  I  know, 
to  treat  this  fracture  with  the  hand  placed  in  a  position  of  extreme 
pronation  ;  but  the  case  has  been  supposed  for  the  purpose  of  render- 
ing the  argument  more  intelligible.  The  usual  practice  is  to  place 
the  forearm  and  hand  in  a  position  midway  between  supination  and 
pronation,  and  then  to  lay  it  across  the  body  at  a  right  angle  with  the 
arm ;  but  it  is  plain  that  the  same  objection,  differing  only  in  degree, 
will  apply  to  this  position  as  to  that  of  pronation.  The  axes  of  the 
two  fragments  are  not  made  to  correspond,  since,  while  the  lower  frag- 
ment is  only  half  rotated  outwards,  the  upper  fragment  is  completely, 
and  the  result  of  the  union  must  be  the  loss  of  one-half  the  power  of 
supination  in  the  hand. 

It  is  only,  then,  by  complete  supination  of  the  hand  during  treatment 
that  this  difficulty  can  be  avoided,  and  I  have  no  doubt  that  we  ought 
to  adopt  this  plan  whenever  it  is  practicable  to  do  so,  or  whenever  we 
are  not  hindered  by  serious  obstacles ;  and  the  only  obstacle  which 
occurs  to  me  as  likely  to  interpose  itself,  is  the  practical  one  which 
most  surgeons  must  have  experienced  in  treating  all  injuries  of  the 
forearm,  whether  fractures,  or  only  severe  contusions  of  the  muscles, 
&c.,  namely,  the  constant  and  almost  uncontrollable  tendency  of  the 
hand  to  assume  the  prone  or  semi-prone  position.  This  is  due,  no 
doubt,  to  the  great  preponderance  of  the  power  of  the  pronators;  and 


FEACTURES  OF  THE  MIDDLE  OF  THE  EADIUS. 


271 


Fig.  76. 


sucli  is  the  resistance  which  they  afford  to  supination  that  it  is  often 
quite  impossible  to  Lay  the  hand  upon  its  back  while  the  forearm  is 
across  the  body,  and  if  accomplished,  the  position  generally  becomes 
in  a  few  hours  so  painful  as  to  be  unendurable.  By  extending  the 
arm,  however,  and  laying  it  upon  a  pillow,  the  hand  will  be_  found 
attain  to  rest  easily  upon  its  back,  because  in  this  way  we  avail  our- 
selves of  the  outward  rotation  of  the  humerus  at  the  shoulder-joint. 

It  has  already  been  stated  that  of  the  whole  number  of  fractures  of 
this  bone  seen  by  me,  amounting  in  all  to  just  sixty,  only  two  be- 
longed to  the  middle  third.  An  observation  which  is  in  striking  con- 
trast with  the  remark  of  Chelius,  that  it  is  broken  most  frequently  m 
its  middle. 

Generally  the  fragments  incline  toward  the  ulna,  but  they  may  also 
be  carried  either  forwards  or  backwards,  according  to  the  direction 
and  force  of  the  blow,  or  the  seat  of  the  fracture. 

A  laboring  man,  ^t.  35,  broke  the  radius  near  the  lower  end  of  the 
middle  third°  On  the  same  day  I  replaced  the  fragments  as  well  as 
I  could  in  the  midst  of  the  swelling  which  had  already 
occurred,  and  applied  two  broad  and  well-padded  splints, 
one  to  the  palmar  and  one  to  the  dorsal  surface  of  the 
forearm. 

On  the  twenty-eighth  day  I  first  discovered  that  the 
fragments  were  projecting  in  front,  and  I  at  once  pro- 
posed to  thrust  them  back  by  force,  but  the  patient  de- 
clined allowing  me  to  do  so.  I  then  applied  a  compress 
near  the  summit  of  the  projection,  but  not  exactly  upon 
it,  lest  it  should  produce  ulceration,  and  secured  over 
this  a  firm  splint.  At  first,  this  seemed  to  produce  a 
change  in  the  fragments,  but  after  a  couple  of  weeks  I 
found  there  was  no  improvement,  and  it  was  discon- 
tinued. About  six  months  after  the  fracture  occurred, 
this  man  had  the  same  arm  terribly  lacerated  in  a  rail- 
road accident,  and  I  was  obliged  to  amputate  near  the 
shoulder-joint;  and  I  thus  obtained  the  broken  radius. 
The  bone  was  firmly  united,  but  with  an  angle,  salient 
forwards,  of  about  ten  degrees.  There  was  no  inclina- 
tion toward  the  ulna. 

My  impression  is  that  these  fragments  were  never 
completely  replaced,  a  point  which  I  couldnot  well  de- 
termine at  first  on  account  of  the  rapid  effusion.  If  they 
had  been,  I  think  they  could  have  been  retained  in 
place  with  the  appliances  used.  Almost  every  day  the  limb  was  ex- 
amined, and  as  often  as  every  fourth  or  fifth  day  the  dressings  were 
removed  and  carefally  reapplied.  And  only  once  did  they  become 
so  loose  as  not  to  afibrd  the  requisite  support,  and  this  at  a  period 
too  late  to  have  occasioned  the  deformity. 

We  ought  not  to  be  deceived,  therefore,  and  promise  too  confidently 
a  perfect  Timb,  even  when  but  the  middle  of  the  radius  is  broken,  since 
we  may  not  always  be  certain  that  the  ends  are  well  replaced,  or  per- 
haps they  may  become  displaced  subsequently,  and  in  either  case  we 


Fracture     of   the 
shaft  of  the  radius. 


272  FRACTURES    OF    THE    RADIUS. 

are  not  likely  to  discover  the  deformity  until  the  swelling  has  sub- 
sided, and  it  is  too  late  to  apply  the  remedy. 

In  the  treatment  of  fractures  of  the  middle  third,  the  same  rules, 
with  only  slight  modifications,  will  be  applicable,  as  in  fractures  of  both 
bones.  Two  straight,  long,  and  broad  splints  must  be  applied  after 
being  carefully  padded ;  and  especial  attention  should  be  paid  to  the 
tendency  of  the  fragments  to  become  displaced  forwards  and  toward 
the  ulna  through  the  action  of  both  the  biceps  and  the  pronator  radii 
teres ;  a  tendency  which  may  in  some  measure  be  provided  against  by 
flexion  of  the  arm,  but  which  must  be  overcome  chiefly  by  steady  and 
well-adjusted  pressure,  near,  but  not  upon,  the  ends  of  the  fragments. 

Fractures  of  the  lower  third,  occurring  above  the  line  of  Colles'  frac- 
ture, are  almost  as  rare  as  fractures  of  the  middle  or  upper  thirds.  I 
have  met  with  five ;  one  of  which  it  will  be  proper  to  relate  as  a  repre- 
sentative example. 

Geo.  Vogel,  aet.  30,  was  admitted  to  the  Buffalo  Hospital  of  the  Sis- 
ters of  Charity,  Nov.  2,  1852,  with  a  fracture  of  the  right  radius  about 
three  and  a  half  inches  above  its  lower  end.  The  hand  was  proned, 
and  inclined  to  the  radial  side;  while  the  broken  ends  of  the  radius  fell 
against  the  ulna,  from  which  it  was  found  difficult  to  separate  them. 
The  lower  end  of  the  ulna  was  prominent,  and  projecting  upon  the 
ulnar  margin  of  the  hand. 

I  was  unable  completely  to  separate  the  fragments  of  the  radius  from 
the  ulna,  by  either  pressure  with  my  fingers  between  the  bones,  or  by 
seizing  upon  them  with  ray  thumb  and  fingers.  Having,  however, 
adjusted  them  as  well  as  possible,  I  flexed  the  arm,  and  applied  a 
broad  and  well-padded  splint  to  the  palmar  surface  of  the  forearm,  se- 
curing it  in  place  with  a  paste  bandage.  These  dressings  were  finally 
removed  at  the  end  of  four  weeks,  when  I  found  scarcely  any  displace- 
ment or  deformity  remaining. 

Most  of  these  fractures,  when  properly  treated,  result  in  perfect  limbs. 
In  a  certain  proportion,  however,  it  will  be  found  impossible  effectually 
to  resist  the  action  of  the  pronator  radii  teres  and  of  the  quadratus,  and 
the  fragments  will  unite  at  an  angle  resting  against  the  ulna,  and  some- 
times, by  the  interposition  of  intermediate  callus,  they  will  become 
firmly  united  to  the  ulna.  Occasionally  also,  especially  where  the 
fracture  has  been  produced  by  a  fall  upon  the  hand,  and  the  radio- 
ulnar ligaments  of  the  wrist  have  been  torn  or  stretched,  the  lower 
end  of  the  ulna  will  be  found  to  project  permanently,  and  the  hand 
to  fall  more  or  less  to  the  radial  side. 

Of  the  fifty-six  fractures  belonging  to  the  lower  third  of  the  radius, 
forty-eight  traversed  the  bone  completely  and  were  near  the  lower 
end,  or  within  from  half  an  inch  to  one  inch  and  a  half  from  the  artic- 
ular surface;  all  being  included  in  those  fractures  called  "  Colles'  frac- 
tures," most  of  which  were  no  doubt  true  fractures,  and  probably  a 
small  proportion  separations  of  the  epiphysis. 

Colles  described  this  fracture  as  occurring  always  about  one  inch 
and  a  half  above  the  carpal  end  of  the  bone ;  but  Robert  Smith,  who 
has  carefully  examined  all  of  the  cabinet  specimens  he  could  find, 
about  twenty-three  in  number,  has  never  seen  the  line  of  fracture 


COLLES'   FRACTUEE.  273 

removed  fartber  tban  one  inch  from  the  lower  end  of  the  bone,  and 
in  several  specimens  it  was  within  one-quarter  of  an  inch  of  this  ex- 
tremity. Dupuj'tren  has  also  described  the  fracture  as  occurring  from 
three  to  twelve  lines  above  the  joint.  I  think  I  have  found  the  frac- 
ture generally  as  low  as  these  latter  surgeons  have  placed  it,  but 
occasionally  as  high  as  it  was  placed  by  Colles. 

Fi2.  77. 


Fracture  of  radius  near  its  lower  end. 


Case.  A  woman,  aet.  40,  fell  upon  the  side-walk,  striking  upon  the 
palm  of  her  left  hand.  She  was  brought  immediately  to  my  office, 
and  I  found  the  radius  was  broken  about  one  inch  and  a  half  above 
the  wrist.  The  lower  fragment  was  tilted  back  considerably.  Hand 
proned. 

Placing  my  thumb  against  the  back  of  the  lower  fragment,  it  was 
easily  restored  to  position,  and  with  only  a  slight  crepitus.  When 
my  thumb  was  removed  it  manifested  no  tendency  to  displacement. 
The  arm  was  dressed  with  a  curved  palmar  splint,  secured  in  place 
with  a  roller  applied  moderately  tight.  On  the  seventh  day  a  straight 
splint  was  substituted  for  the  curved.  The  arm  was  examined  almost 
every  day,  and  the  dressings  occasionally  renewed  until  the  twenty- 
sixth  day,  when  the  splint  was  finally  removed.  The  wrist  was  at 
this  time  only  slightly  anchylosed,  and  there  seemed  to  be  no  deformity 
or  imperfection  remaining.  Passive  motion,  which  had  been  practised 
at  each  removal  of  the  dressings,  was  directed  to  be  continued. 

Case,  A  boy,  ddt.  11,  was  brought  to  me  having  just  fallen  from  a 
pair  of  stilts.  His  right  radius  was  broken  transversely,  three-quarters 
of  an  inch  above  the  wrist,  and  the  lower  fragment  was  much  tilted 
back ;  the  lower  end  of  the  ulna  was  prominent,  and  the  hand  fell  to 
the  radial  side. 

Pushing  from  behind,  the  lower  fragment  was  made  to  resume  its 
place,  and  the  deformity  immediately  disappeared.  It  was  noticed, 
however,  that  it  required  unusual  force  to  accomplish  this,  but  it  was 
not  found  necessary  to  use  extension.  There  was  also,  accompanying 
the  reduction,  a  slight  crepitus. 

The  treatment  was  the  same  as  in  the  first  case,  except  that  the 
curved  splint  was  employed  throughout.  Little  or  no  deformity  ex- 
isted when  the  dressings  were  removed. 

Case.  George  Lofinch,  ast.  42,  fell  upon  an  icy  side-walk,  striking 

upon  the  palm  of  his  left  hand.     Fracture  three-quarters  of  an  inch 

above  the  lower  end.     Fragment  displaced  backwards.     A  friend  had 

partially  replaced  the  fragment  by  pushing  upon  it,  before  he  came  to 

18 


274  FEACTURES    OF    THE    RADIUS. 

me.  Within  half  an  hour  after  the  accident  he  was  at  my  office,  and 
I  restored  the  lower  end  of  the  bone  very  easily  to  place  by  pushing 
from  behind  with  my  thumb.  No  extension  was  necessary.  It 
would  not,  however,  remain  in  place  unless  the  forearm  was  proned 
so  that  the  weight  of  the  hand  could  aid  in  the  reteation. 

I  applied  my  own  palmar  splint.  The  recovery  was  rapid  and 
complete. 

Case.  Lewis  Brittin,  set.  60,  fell  from  a  fourth  story  window, 
breaking,  among  other  bones,  the  radius  of  the  right  arm  three-quar- 
ters of  an  inch  above  the  joint.  This  fracture  was  not  discovered 
until  the  fourth  day.  Crepitus  and  motion  were  then  distinct,  but 
there  was  no  displacement.  The  wrist  was  considerably  swollen.  No 
splints  were  applied  ;  and  the  bone  united  promptly,  leaving  no  de- 
formity or  anchylosis. 

Case.  Margaret  Bead,  ast.  48,  fell,  September  23,  1855,  striking  on 
the  palm  of  the  left  hand,  and  breaking  the  radius  about  one  inch  from 
its  lower  end.  One  week  after,  she  came  under  my  care  at  the  hos- 
pital. The  arm  had  been  previously  dressed  carefully  by  one  of  my 
colleagues,  with  curved,  dorsal,  and  palmar  splints ;  but,  on  examina- 
tion, we  found  the  fragments  a  good  deal  displaced.  It  was  found 
necessary  now  to  use  both  extension  and  pressure  from  behind  to  re- 
store the  lower  fragment  to  position.  This  we  finally  succeeded  in 
doing,  and  immediately  splints  were  again  snugly  applied.  Two  days 
after,  on  opening  the  dressings,  the  lower  fragment  was  a  second  time 
found  displaced  backwards.  It  was  again  reduced,  but  only  by  using 
great  force.  Fifteen  days  later,  we  were  pleased  to  find  the  bone  firm 
and  without  deformity. 

Margaret  left  the  hospital  on  the  4th  of  November,  with  her  hand 
and  wrist  still  swollen,  and  with  a  good  deal  of  stiffness  at  the  elbow 
and  wrist-joints. 

Case.  Charles  Stratton,  a  healthy  and  temperate  laborer,  set.  36, 
fell  forwards  from  a  wagon,  Nov.  22,  1854,  striking  upon  the  palm  of 
his  hand,  and  breaking  the  radius  a  little  more  than  one  inch  above  the 
joint.  I  found  the  lower  fragment  displaced  backwards,  and  it  was 
easily  reduced  by  pressure  in  the  opposite  direction.  The  fore  part  of  the 
wrist  being  quite  tender  to  pressure,  the  splint  was  applied  to  the  dorsal 
surface  of  the  forearm.  The  splint  was  pistol-shaped,  and  the  surface 
which  was  applied  to  the  arm  was  padded  with  care;  it  was  secured  in 
place  by  a  few  light  turns  of  a  roller,  and  laid  across  the  body  in  a  sling. 

The  arm  was  seen  by  me  on  each  of  the  succeeding  seven  days,  and 
on  the  third,  fifth,  and  seventh  days,  the  splint  was  removed  com- 
pletely ;  but  on  this  last  day  an  erysipelatous  inflammation  had  com- 
menced in  the  neighborhood  of  the  wrist.  The  splint  and  roller  were 
therefore  not  reapplied,  but  the  limb  was  laid  upon  a  broad  board, 
cushioned  and  covered  with  oiled  silk,  and  cool  water  irrigations  were 
directed.  The  inflammation  soon  subsided,  but  the  splint  was  never 
resumed,  as  the  fragments  were  found  to  stay  in  place  perfectly  with- 
out its  aid.  At  the  end  of  five  weeks,  union  seemed  to  be  consum- 
mated ;  and  one  year  later  the  bone  was  found  to  be  perfectly  straight, 
yet  the  wrist-joint  and  the  finger-joints  remained  stiff",  so  much  so  that 


COLLES'    FRACTURE.  275 

he  was  unable  to  perform  any  labor.  The  stiffness  was,  however, 
gradually  disappearing;  while  all  swelling  and  tenderness  had  long 
ceased. 

The  observations  of  M.  Yollemier  also  have  shown  that,  instead  of 
being  oblique,  as  has  generally  been  supposed,  the  fracture  is  almost 
uniformly  transverse  from  the  palmar  to  the  dorsal  surfaces  of  the 
bone,  and  only  occasionally  slightly  oblique  in  its  other  diameter,  or 
from  the  radial  to  the  ulnar  side.  I  have  seen,  however,  in  the  mu- 
seum of  the  College  of  Physicians  of  Philadelphia,  a  specimen  of  this 
fracture  in  which  the  line  of  fracture  is  transverse,  from  side  to  side, 
but  very  oblique  from  before  backwards,  and  from  below  upwards. 
There  is  also  a  line  of  incomplete  fracture  extending  into  the  joint. 
It  is  united  by  bone,  with  the  usual  displacement  backwards. 

The  observations  of  both  R.  Smith  and  Yollemier  have  shown, 
moreover,  that  the  displacement  of  the  lower  fragment  is  seldom  suffi- 
cient to  enable  it  to  escape  completely  from  the  upper ;  and  that  where, 
in  extremely  rare  instances,  and  in  consequence  of  extraordinary  vio- 
lence, such  complete  separation  does  occur,  a  disruption  of  those 
ligaments  which  attach  the  lower  fragment  to  the  ulna  occurs  also, 
and  the  deformity  becomes  at  once  very  great,  so  that  it  no  longer 
presents  the  peculiar  features  of  Colles'  fracture,  but  resembles  a  dis- 
location. 

In  the  so-called  Colles'  fracture,  the  lower  and  outer  border  of  the 
radius,  or  its  styloid  apophysis,  is  swung  around  or  tilted,  as  it  were, 
upon  the  ulna ;  the  lower  and  inner  border  of  the  same  fragment  being 
retained  in  place  by  the  radio-ulnar  ligaments,  which  do  not  usually 
suffer  a  complete  disruption,  but  only  a  stretching  or  partial  laceration. 
The  upper  or  broken  margin  of  the  lower  fragment,  and  also  the 
ulnar  margin,  undergo  very  little  displacement;  while  the  lower  or 
articular  surface,  and  the  radial  margin,  are  carried  backwards,  up- 
wards, and  outwards. 

Surgeons  have  spoken  of  a  falling  in  of  the  upper  end  of  the  lower 
fragment  toward  the  ulna,  as  an  almost  inevitable  result  of  the  action 
of  the  pronator  quadratus,  and  against  which  tendency  they  have 
sought  carefully  to  provide ;  but  there  is  much  reason  to  believe  that 
any  considerable  degree  of  displacement  in  this  direction  is  a  rare 
event,  and  that,  when  it  does  exist,  it  is  in  consequence  mostly  of  the 
direction  of  the  force  which  has  produced  the  fracture,  rather  than  of 
the  action  of  this  muscle,  only  a  few  of  the  fibres  of  which  are  usually 
attached  to  the  lower  fragment,  and,  in  some  instances,  when  the 
fracture  is  within  a  half  or  a  quarter  of  an  inch  of  the  articulation,  not 
any.  Besides,  there  is  actually  in  these  latter  cases,  no  interosseous 
space  into  which  the  fragment  may  fall,  and  its  displacement  toward 
the  ulna  becomes,  therefore,  impossible. 

Still,  however,  if  one  were  disposed  to  speculate  upon  the  condition 
of  these  parts  after  the  fracture,  it  might  perhaps  be  easy  to  persuade 
ourselves  that  the  action  of  the  pronator  quadratus  upon  the  upper 
fragment,  whose  broken  extremity  was  not  completely  or  at  all  dis- 
engaged from  the  lower,  would  carry  both  fragments  together  toward 
the  ulna.     But  whatever  might  be  the  result  of  our  speculations,  still 


276  FEACTUEES  OF  THE  EADIUS. 

the  fact,  as  proved  by  specimens,  is  not  generally  so ;  and  this  is  not 
the  first  time  that  facts  and  theories  have  disagreed. 

The  truth  is,  that  it  is  unusual  to  find  in  any  of  the  museums  speci- 
mens of  this  fracture  having  thus  united.  But  they  may  be  found 
constantly  tilted  back  in  the  manner  I  have  described,  occasionally 
tilted  forwards,  and,  still  more  rarely,  slightly  displaced  upon  their 
broken  surfaces  antero-posteriorly. 

The  general  absence  of  this  internal  displacement  may  find  its  ex- 
planation in  the  direction  of  the  force  which  generally  produces  this 
fracture,  in  the  occurrence  of  the  fracture  sometimes  at  a  point  so  low 
as  to  render  its  displacement  in  this  direction  impossible,  and  in  the 
breadth  of  the  bone,  at  the  seat  of  the  fracture,  which  does  not  permit 
it  to  fall  laterally  without  actually  increasing  its  length ;  a  circum- 
stance which  its  secure  ligamentous  attachment  to  the  ulna  at  its  op- 
posite extremities,  and  its  complete  apposition  to  the  wrist  and  elbow- 
joint,  do  not  allow. 

The  mistake  of  those  surgeons  who  have  attempted  to  describe  this 
fracture,  has  originated  in  the  appearance  presented  in  nearly  all  re- 
cent fractures  occurring  at  this  point.  The  hand  falls  to  the  radial 
side,  and  seems  to  carry  the  lower  end  of  the  lower  fragment  with  it, 
while  the  lower  end  of  the  ulna  becomes  unnaturally  prominent  in 
front  and  to  the  ulnar  side ;  a  condition  of  things  which  has  naturally 
enough  been  ascribed  to  the  displacement  of  the  upper  end  of  the  lower 
fragment  in  the  direction  of  the  interosseous  space. 

But  this  same  radial  inclination  of  the  hand,  and  prominence  of  the 
ulna,  are  present  frequently  when  the  radius  is  broken  at  its  lower 
end  and  no  displacement  in  any  direction  has  taken  place  ;  and  I  have 
even  observed  it  in  simple  sprains  of  the  wrist,  and  in  the  hands  of 
old  or  feeble  persons  where  all  the  ligaments  have  become  relaxed. 
It  is  seen,  however,  in  a  more  marked  degree  when  the  bone  is  actu- 
ally both  broken  and  displaced  backwards  in  its  usual  direction.  In 
short,  the  deformity  in  question  is  due,  in  a  large  majority  of  instances, 
to  the  relaxation,  stretching,  or  more  or  less  disruption  of  the  radio- 
ulnar ligaments,  which  permits  the  hand  to  fall  to  the  radial  side  by  a 
simple  rotatory  movement  over  its  articular  surface.  For  this  rea- 
son, also,  because  these  ligaments  once  lengthened  or  broken  can  never, 
or  only  after  a  lapse  of  many  years,  be  completely  restored,  this  de- 
formity may  be  expected  to  continue,  however  exact  and  perfect  may 
be  the  bony  union. 

It  must  be  added,  however,  that,  so  long  as  the  tilting  remains,  the 
articular  surface  is  actually  presenting  somewhat  to  the  radial  side. 
While  in  the  normal  condition  it  presents  downwards,  forwards,  and 
inwards,  it  now  presents,  when  the  displacement  is  considerable,  down- 
wards, backwards,  and  outwards. 

Diday  maintained  that  there  existed  usually  in  this  fracture  an  over- 
lapping or  shortening  of  the  bone  in  its  entire  diameter,  and  Vollemier 
thought  that  the  specimens  which  he  had  examined  proved  that  an 
impaction  was  almost  universal. 

Both  of  these  opinions  it  seems  to  me,  have  been  successfully  com- 
bated by  Robert  Smith ;  the  shortening  observed  by  Diday  being  found 


COLLES     FRACTURE. 


277 


only  on  that  side  of  tlie  bone  to  which  the  hand  inclines,  and  being 
the  result  of  the  motion  of  the  lower  fragment  already  described;  and 
the  appearance  of  impaction  being  due  to  the  ensheathing  callus  which 
is  deposited  usually,  if  the  displacement  is  allowed  to  continue,  in  the 
retiring  angle,  opposite  the  seat  of  fracture. 

These  are  questions,  however,  requiring  for  their  decision  a  very 
careful  study  of  specimens,  and  in  relation  to  which  further  observa- 
tions may  be  necessary. 

Meanwhile  there  is  no  doubt  that  occasional  examples  may  be  found 
illustrating  one  or  more  of  all  these  varieties  of  displacement,  and  that 
to  the  impaction  is  sometimes  added  a  comminution  of  the  lower  frag- 
ment, the  lines  of  the  fracture  extending  freely  into  the  joint.  One  of 
the  most  curious  examples  of  which  has  been  reported  by  Dr.  Bigelow, 
of  Boston.  The  patient  had  fallen,  and  being  otherwise  seriously  in- 
jured, ultimately  died  in  the  Massachusetts  Hospital.  At  first  he  had 
only  complained  of  lameness  at  the  wrist,  as  if  it  had  been  severely 
sprained ;  but  at  the  end  of  several  days  the  joint  became  swollen,  and 
from  the  persistence  of  the  swelling  Dr.  Bigelow  was  led  to  diagnosticate 
a  stellate  crack  in  the  articulating  extremity  of  the  radius,  he  having 
met  with  a  similar  case  two  years  before,  when  a  patient  with  the  same 
symptoms  had  died  of  other  injuries,  and  exhibited  a  crack  in  the  same 
place,  but  less  extensive  than  in  this  case.  There  was  found  in  this 
last  example,  a  star-shaped  fissure  on  the  articulat- 
ing surface,  without  displacement.  These  fissures 
penetrated  the  shaft  for  an  inch  or  more.  Dr.  Bige- 
low thought  that  the  bones  of  the  wrist  acted  as  a 
wedge  to  spread  the  corresponding  hollow  of  the 
articulating  extremity;  and  that  this  specimen 
would  explain  the  persistence  of  some  cases  of 
sprained  wrist.^ 

Eobert  Smith  has  described  a  fracture  occurring 
at  the  same  point,  and  probably  possessing  the 
same  characters  as  Colles'  fractures ;  in  which  the 
lower  fragment  is  thrown  forwards  instead  of  back- 
wards, and  which  has  generally  been  the  result  of 
a  fall  upon  the  back  of  the  hand.  There  is  no 
such  specimen,  however,  in  any  of  the  pathological 
collections  in  Dublin,  nor  has  Mr.  Smith  ever  seen 
a  specimen  obtained  from  the  cadaver,  although 
he  reports  a  case  which  fell  under  his  observation 
in  practice. 

I  have  myself  seen  one  such  case,^  but  I  regret 
to  say  that  my  examination  of  the  condition  of  the 
arm  was  not  such  as  to  enable  me  to  add  anything  to  the  information 
already  possessed  upon  this  subject;  indeed,  until  we  shall  have  an 
opportunity  of  studying  it  in  the  cadaver,  we  cannot  speak  very  de- 
finitely of  its  anatomical  characters. 


Fig.  78. 


Bigelow's  case  of  com- 
minuted fracture  of  the 
lower  end  of  tlie  radius. 


'  Boston  Med.  and  Surg.  Journ.,  vol.  Iviii.  p.  99. 
2  Trans.  Am.  Med.  Assoc,  vol.  ix.  p.  145. 


278  FRACTURES    OF    THE    RADIUS. 

Nelaton  observes  that  all  the  varieties  of  this  fracture  which  he  has 
seen  are  often  accompanied  with  fracture  of  the  styloid  apophysis  of 
the  ulna,  and  with  a  tearing  of  the  triangular  ligament,  I  am  not 
aware  that  any  other  writer  has  made  the  same  observation  in  relation 
to  the  frequent  occurrence  of  a  fracture  of  the  styloid  apophysis  of  the 
ulna,  and  I  think  the  accident  is  not  so  common  as  the  remark  of 
Nelaton  would  lead  us  to  suppose. 

Dr.  Butler,  House  Surgeon  to  the  Brooklyn  Hospital,  reports  a  case 
of  fracture  of  the  right  radius  at  the  junction  of  the  middle  and 
lower  thirds,  accompanied  with  a  fracture  also  of  the  styloid  apophy- 
sis in  the  same  bone.  The  accident  occurred  in  a  lad  fourteen  years 
old,  who  had  fallen  from  a  height  of  thirty  feet  upon  the  pavement. 
The  lower  fracture  commenced  at  the  base  of  the  styloid  process  of  the 
radius,  and  extended  down  obliquely  into  the  wrist-joint,  breaking  off 
about  one-fifth  of  the  articular  surface.  The  process  was  drawn  up 
on  the  posterior  surface  of  the  radius,  about  one  inch  and  a  half,  by 
the  supinator  radii  longus  muscle.  It  was  movable,  but  in  consequence 
of  the  contusion  and  swelling,  could  not  be  returned  to  its  place.  The 
hand  occupied  the  same  position  that  it  does  in  Colles'  fracture. 

On  the  eighth  day  an  attempt  was  made  to  force  down  the  process 
with  a  compress  secured  by  adhesive  plaster  straps;  but  it  could  not 
be  done.  The  hand  and  arm  were  confined  also  to  a  pistol  shaped  splint ; 
ulcerations  ensued  from  the  pressure  of  the  compress,  and  the  process 
was  laid  bare,  but,  it  finally  became  united  in  its  abnormal  position; 
the  motions  of  the  wrist,  however,  were  not  impaired,  and  the  power 
of  pronation  and  supination  soon  returned.^ 

I  believe  I  have  seen  two  examples  of  a  fracture  commencing  on 
the  radial  side  of  the  bone  and  terminating  in  the  joint,  the  separated 
fragment  including  considerable  more  than  the  apophysis;  but  neither 
of  these  cases  has  been  verified  by  an  autopsy. 

A  boy,  £et.  18,  fell  twelve  feet,  striking  upon  the  right  hand  and 
wrist.  I  examined  him  at  the  hospital  soon  after,  and  thought  I  could 
distinctly  feel  the  line  of  fracture  extending  very  obliquely  downwards, 
from  the  radial  side  into  the  joint,  and  without  traversing  the  entire 
diameter  of  the  bone.  The  fragment  thus  separated  fell  backwards, 
and  the  hand  inclined  to  the  radial  side.  Eeduction  was  immediately 
accomplished  by  pushing  the  fragment  forwards,  and  the  arm  was 
dressed  with  straight  palmar  and  dorsal  splints,  with  compresses,  &c. 
He  was  soon  dismissed. 

Five  months  after  I  found  the  bones  united  without  displacement, 
and  the  motions  of  the  joint  were  perfect. 

A  man,  ast.  88,  fell  upon  the  palm  of  his  left  hand.  On  the  same 
day  he  was  admitted  to  the  Buffalo  Hospital  of  the  Sisters  of  Charity, 
and  the  diagnosis  was  confirmed  by  Drs.  Lay  and  Lemon.  The  symp- 
toms were  the  same  as  in  the  first  case,  and  we  adopted  the  same  treat- 
ment. On  the  thirty-first  day,  it  was  noted  in  the  hospital  record,  that 
"  the  splints  have  been  for  some  time  removed,  but  the  wrist  remains 
swollen  and  stiff.  The  lower  end  of  the  ulna  is  prominent,  but  the 
fragments  of  the  radius  seem  to  be  in  exact  line." 

'  New  York  Journ.  of  Med.,  1857. 


baeton's  feactuee.  279 

In  the  first  volume  of  the  Pldladelphia  Medical  Examiner  (1838) 
will  be  found  a  description  by  J.  Ehea  Barton,  of  Philadelphia,  of  a 
form  of  fracture  occurring  through  the  lower  end  of  the  radius,  which 
is  probably  much  less  common  than  Colles'  fracture,  and  which  had 
hitherto  escaped  the  notice  of  surgeons.  Its  peculiarity  consists  in  the 
Ime  of  fracture  extending  very  obliquely  from  the  articulation,  up- 
wards and  backwards,  separating  and  displacing  the  whole,  or  only  a 
portion,  as  the  case  may  be,  of  the  posterior  margin  of  the  articulating 
surface.  I  have  not  recognized  this  fracture  in  any  instance  which 
has  come  under  my  own  observation,  nor  have  I  been  able  to  find  a 
cabinet  specimen  in  any  pathological  collection.  Dr.  Barton  was  not 
able  to  prove  the  correctness  of  his  diagnosis  by  an  autopsy,  and  the 
only  well-authenticated  example  which  I  can  find  upon  record  is  that 
to  which  Malgaigne  has  alluded,  as  having  been  seen  by  M.  Lenoir, 
and  of  which  an  account  was  published  in  the  Archives  Generale  de 
Medecinem  1839.  M.Lenoir  believed  it  to  be  a  simple  luxation  of  the 
hand  backwards,  but  the  patient  having  died,  he  was  able  to  correct 
his  diagnosis  by  an  autopsy.  A  considerable  fragment  had  been 
broken  from  the  posterior  lip  of  the  articular  surface,  the  line  of  frac- 
ture being  from  below  upwards,  and  from  before  backwards.  This 
fragment  had  become  displaced  upwards  and  backwards,  carrying  with 
it  the  carpal  bones,  and  producing  thus  the  appearance  of  a  simple 
dislocation,'  I  believe  that  the  accident  so  carefully  described  by 
Barton  was  either  a  Colles'  fracture,  or  a  fracture  simply  of  the  radial 
margin,  of  which  I  have  given  two  supposed  examples,  with  the  usual 
signs  of  which  his  account  so  exactly  coincides,  and  that  it  was  not  a 
fracture  of  the  posterior  lip  of  the  articulating  surface,  as  he  believed. 

Fifty  examples  of  simple  fracture  near  the  lower  end  of  the  radius 
have  furnished  no  cases  of  non-union,  nor  indeed  do  I  remember  ever 
to  have  seen  the  union  delayed;  yet  only  sixteen  are  positively  known 
to  have  left  no  perceptible  deformity  or  stiffness  about  the  joint :  it  is 
probable,  however,  that  the  number  of  perfect  results  might  be  ex- 
tended to  twenty.  In  one  example,  the  case  of  a  man  whose  arm  was 
broken  in  Germany,  when  he  was  only  ten  years  old,  the  fragments 
of  the  radius  were  driven  into  each  other,  or  overlapped  one  inch,  and 
the  ulna  had  been  displaced  downwards  toward  the  fingers  the  same 
distance.  This  was  examined  twelve  years  after  the  accident,  and  he 
had  then  a  very  useful  arm.  Twice  I  have  found  the  wrist  and  finger- 
joints  quite  stiff  after  a  lapse  of  one  year;  in  one  case  I  have  found 
the  same  condition  after  two  years ;  in  one  case  after  three  years,  and 
in  two  cases  after  five  years. 

If  we  confine  our  remarks  to  Colles'  fracture,  the  deformity  which 
has  been  observed  most  often,  and,  indeed,  with  only  rare  exceptions, 
being  found  in  some  degree  more  or  less  in  several  of  those  cases 
which  I  have  marked  as  perfect,  consists  in  a  projection  of  the  lower 
end  of  the  ulna  inwards  and  generally  a  little  forwards.  In  a  large 
majority  of  cases  this  is  accompanied  with  a  perceptible  falling  of  the 
hand  to  the  radial  side,  while  in  a  few  it  is  not.     After  this,  in  point 

'  Malgaigne,  Traite  des  Frac,  etc.,  torn.  ii.  p.  700. 


280  FEACTUEES  OF  THE  EADIUS. 

of  frequency,  I  have  met  with  the  backward  inclination  of  the  lower 
fragment,  Robert  Smith  found  this  displacement  almost  constant  in 
the  cabinet  specimens  examined  by  him ;  and  it  is  very  probable  that 
nearly  all  of  the  examples  examined  by  myself  would  present  more  or 
less  of  the  same  deviation  upon  the  naked  bone;  but  in  the  living 
examples  a  slight  deviation  would  be  concealed  by  the  numerous 
tendons  which  cover  this  part  of  the  arm,  and  perhaps  by  some  per- 
manent efl'usions,  of  which  I  shall  speak  more  particularly  presently. 

There  remains  for  a  long  time,  in  a  majority  of  cases,  a  broad,  firm, 
uniform  swelling  on  the  palmar  surface  of  the  forearm,  commencing 
near  the  upper  margin  of  the  annular  ligament  and  extending  upwards 
two  inches  or  more.  This  swelling  continues  much  longer  in  old  and 
feeble  persons  than  in  the  young  and  vigorous.  It  is  pretty  generally 
proportioned  to  the  amount  of  anchylosis  existing  at  the  wrist  and 
finger-joints,  and  it  disappears  usually,  pari  passu^  with  these  condi- 
tions. There  can  be  no  doubt  that  this  phenomenon  is  due  to  an 
effusion,  first  serous,  and  subsequently  fibrinous,  along  the  sheaths  of 
the  tendons ;  and  it  is  as  often  present  after  sprains  and  other  severe 
injuries  about  this  part,  as  in  fractures.  In  many  cases,  however,  its 
prolonged  continuance  and  its  firmness  have  led  to  a  suspicion  that 
the  bones  were  displaced,  a  suspicion  which  only  a  moderate  degree 
of  care  in  the  examination  ought  easily  to  dispel.  A  similar  effusion, 
but  in  less  amount,  is  frequently  seen  also  on  the  back  of  the  hand, 
below  the  annular  ligament.  When  both  exist  simultaneously  the 
appearances  of  deformity  and  of  displacement  are  greatly  increased. 
Here, 'then,  we  shall  find  a  partial  explanation  of  the  anchylosis  in 
the  wrist  and  finger-joints,  which,  often  for  a  time  almost  complete, 
continues  occasionally  many  months,  or  even  years,  if,  indeed,  it  is  not 
perpetual.  An  anchylosis  produced,  not,  as  has  generally  been  affirmed, 
by  extension  of  the  inflammation  to  these  joints,  but  by  the  inflamma- 
tory effusion  and  consequent  adhesions  along  the  thecse  and  serous 
sheaths,  through  which  the  tendons  all  pass  in  their  course  to  the 
hands  and  fingers;  and  by  simple  contraction  of  the  articular  liga- 
ments as  a  consequence  of  disuse.  The  fingers  are  quite  as  often  thus 
anchylosed  as  the  wrist-joint  itself,  a  circumstance  which  is  wholly 
inexplicable  on  the  doctrine  that  the  anchylosis  is  due  to  an  inflam- 
mation in  the  joints.  Indeed,  I  have  seen  the  fingers  rigid  after  many 
months,  when,  having  observed  the  case  throughout  myself,  I  was 
certain  that  no  inflammatory  action  had  ever  reached  them. 

Nor  is  it  any  more  difficult  to  show,  I  think,  that  the  anchylosis  of 
the  wrist-joint  is  not  due  to  a  malposition  of  its  articular  surfaces,  as 
has  often  been  asserted  in  the  written  treatises ;  for,  if  the  anchylosis 
of  the  fingers  in  all  these  cases  is  known  to  be  the  result  of  inflam- 
mation of  the  tendinous  sheaths  and  of  contraction  of  the  articular 
ligaments,  why  shall  we  refuse  to  accept  the  same  explanations  for 
anchylosis  of  the  wrist? 

The  most  superficial  examination  of  the  mechanism  of  this  joint 
ought  to  satisfy  us  that  any  moderate  or  even  considerable  malposition 
of  the  lower  fragment  after  a  fracture  of  the  radius  is  not  sufficient  in 
itself  to  occasion  anchylosis.     It  is  true  that  the  direction  of  the 


COLLES'    FEACTURE.  281 

articular  surface  of  the  radius  is  changed  also,  and  that,  while  it  was 
directed  downwards,  forwards,  and  to  the  ulnar  side,  it  is  now,  perhaps, 
directed  downwards,  backwards,  and  to  the  radial  side.  But  of  what 
consequence  is  this  so  long  as  the  carpal  bones,  with  which  alone  this 
bone  is  articulated,  preserve  their  relations  to  the  radius  unchanged  ? 

I  suspect  it  will  be  found  very  difficult  for  any  one,  however 
ingenious,  to  ofier  even  a  plausible  argument  in  defence  of  this  doc- 
trine of  anchylosis,  as  applied  to  this  fracture,  so  long  and  so  posi- 
tively affirmed  that  to-day  it  is  thought  to  be  established. 

But  if  any  other  evidence  than  such  as  I  have  furnished  be  de- 
manded, it  may  be  supplied  by  the  experience  of  most  surgeons  in 
examples  of  anchylosis  without  displacement;  in  examples  of  displace- 
ment without  anchylosis,  but  in  which  the  anchylosis  has  yielded 
gradually  to  the  lapse  of  time,  while  the  displacement  has  continued. 
Examples,  also,  of  all  these  results,  so  incompatible  with  the  supposi- 
tion named,  have  frequently  come  under  my  own  notice,  some  of 
which  I  have  already  mentioned  in  this  chapter,  and  many  more  of 
which  may  be  found  in  my  report  On  Deformities  after  Fractures. 

To  what  I  have  said  as  to  the  prognosis  in  these  accidents,  I  may 
be  permitted  to  add  the  opinion  of  our  distinguished  countryman,  Dr. 
Mott,  given  in  a  clinical  lecture  before  his  class  in  the  University  of 
New  York. 

"Fractures  of  the  radius  within  two  inches  of  the  wrist,  where 
treated  by  the  most  eminent  surgeons,  are  of  very  difficult  manage- 
ment so  as  to  avoid  all  deformity ;  indeed,  more  or  less  deformity  may 
occur  under  the  treatment  of  the  most  eminent  surgeons,  and  more  or 
less  imperfection  in  the  motion  of  the  wrist  or  radius  is  very  apt  to 
follow  for  a  longer  or  shorter  time.  Even  when  the  fracture  is  well 
cured,  an  anterior  prominence  at  the  wrist,  or  near  it,  will  sometimes 
resalt  from  swelling  of  the  soft  parts." 

To  which  the  reporter,  himself  a  surgeon  in  the  city  of  New  York, 
adds : — 

"  As  the  above  opinion  of  Professor  Mott  coincides  with  my  own 
observations,  both  in  Europe  and  in  this  city,  as  well  as  with  many  of 
our  most  distinguished  surgical  authorities,  I  venture  to  hope  that  it 
may  assist  in  removing  some  of  the  groundless  and  ill-merited  asper- 
sions which  are  occasionally  thrown  on  the  members  of  our  profession 
by  the  ignorant  or  designing."^ 

Of  gangrene  as  an  occasional  result  of  this  fracture,  I  shall  speak 
presently,  in  connection  with  the  subject  of  treatment. 

The  peculiar  character  of  the  displacement  which  characterizes 
Colles'  fracture,  and  the  constant  difficulty  experienced  by  surgeons 
in  obviating  deformity,  have  led  to  much  speculation  and  ingenious 
invention  ;  and  modern  surgeons,  especially,  have  thought  it  necessary 
to  introduce  here  an  essential  modification  of  the  usual  apparel  for 
broken  forearms.  This  modification  consists  in  employing  a  pistol- 
shaped  splint,  instead  of  a  straight  splint,  by  means  of  which  the  hand 
may  be  thrown  more  or  less  strongly  to  the  ulnar  side. 

'  Boston  Med.  and  Surg.  Journ.,  vol.  xxv.  p.  289. 


282 


FEACTUEES    OF    THE    EADIUS. 


Heister^  speaks  of  inclining  the  hand  toward  the  ulna,  while  re- 
ducing a  fracture  of  the  radius,  but  when  the  reduction  has  been 
effected  he  recommends  a  straight  splint. 

Among  the  first  to  advocate  the  permanent  confinement  of  the  hand 
in  this  position,  were  Mr.  Cline,  of  London,^  and  M.  Dupuytren,  of 
Paris.^  Mr,  Cline,  and  after  him  Bransby  Cooper,''  and  Mr.  South,^ 
recommend  the  ordinary  straight  splints  for  the  forearm,  but  the 
rollers  by  which  the  splints  are  secured  in  place  are  not  permitted  to 
extend  lower  than  the  wrist ;  so  that  when  the  forearm  is  suspended 
in  a  sling,  in  a  state  of  semi-pronation,  the  hand  shall  fall  by  its  own 
weight  to  the  ulnar  side. 

Dupuytren,  and,  after  him,  Chelius,  adopt,  in  addition  to  the  palmar 
and  dorsal  splints,  the  *'  attelle  cubitale,"  or  ulnar  splint ;  which  is  a 
gutter,  composed  of  steel,  iron,  tin,  or  some  other  metal,  and  made  to 
fit  the  ulnar  margin  of  the  forearm  and  hand,  when  the  hand  is  drawn 
forcibly  to  the  ulnar  side.  Blandin,^  N^laton,^  and  Goyraud,^  also, 
under  certain  contingencies  employ  the  same.  An  instrument  similar 
to  this,  but  constructed  of  wood  and  gutta  percha,  and  much  less 
curved,  has  been  invented  by  Welch. 

Fig.  79. 


Welch's  "  ulnar  splint"  for  fracture  of  the  radius. 


Most  surgeons,  however,  employ  either  a  palmar  or  a  dorsal  splint; 
or  both  palmar  and  dorsal  splints,  constructed  with  a  knee,  or  pistol- 
shaped,  and  they  thus  avoid  the  necessity  of  the  ulnar  splint.     Thus, 

Fig.  80. 


Nelaton's  splint  for  fracture  of  the  radius. 

'  De  Lavrentii  Heisteri,  Institutiones  Chirurgicse,  pars  prima,  p.  2U2,  Amsterdam 
ed.,  1739. 

^  Malgaigne,  Traite  de  Frac,  etc.,  torn.  i.  p.  614,  Paris  ed. 

*  Dupuytren,  ou  Bones,  London  ed.,  p.  140. 

*  B.  Cooper,  Lectures  on  Surg.,  p.  232,  Amer.  ed. 

^  Chelius's  Surg.,  vol.  i.  p.  613.  ^  Malgaigne,  op.  cit.,  torn  i.  p.  614. 

■^  Nelatou,  Elem.  de  Path.  Chir.,  tom.  i.  p.  747.  ^  Ibid.,  p.  746. 


COLLES'   FRACTUEE. 


283 


Nelaton/  Robert  Smith,^  and  Erichsen,'  recommend  this  peculiar  form 
only  in  the  dorsal  splint ;  while  Bond,-*  Hays/  E.  P.  Smith,^  and  others, 
especially  among  the  Americans,  place  the  pistol-shaped  splint  against 

Fig.  81. 


Bond's  splint. 
Fig.  82. 


Hays'  splint. 
Fig.  83. 


E.  P.  Smith's  splint.     Surface  applied  to  forearm.     A.  Forearm  piece,  made  of  felt,  with  incurvated 
mai'gius. 


Fig.  84. 


C  — -.. 


E.  P.  Smith's  splint.  B.  Opposite  surface,  i?,  the  hand-block,  is  connected  with  the  forearm  piece  by- 
two  circular  brass  plates,  which  move  upon  each  other,  in  order  that  the  hand-block  may  assume  any 
desired  angle  with  the  arm.  In  this  way  it  may  be  adapted  to  either  the  right  or  left  arm.  It  is  fixed 
by  a  nut  seen  on  the  brass  plate.    The  letters  O  C  indicate  the  extent  of  motion  allowed  to  the  hand-block. 


'  Nelaton,  op.  cit.,  p.  747. 
'  Erichsen,  Surgery,  p.  215. 
5  Ibid.,  Jan.,  1853. 


2  R.  Smith,  op.  cit.,  p.  168. 
^  Bond,  Amer.  Journ.  Med.  Sci.,  April,  1852. 
E.  P.  Smith,  Buffalo  Med.  Journ.,  vol.  ix.  p.  225. 


284 


FRACTUEES    OF    THE    RADIUS. 


the  palmar  surface  of  the  forearm  and  hand,    Welch  has  manufactured,    ' 
also,  as  a  substitute  for  his  single  ulnar  splint,  a  palmar  and  a  dorsal 
splint,  made  of  gutta  percha  and  wood. 

Fig.  85. 


Welch's  palmar  splint. 

Fig.  86. 


Welch's  dorsal  splint. 

A  few  modern  surgeons  have  not  seen  fit  to  adopt  this  peculiar 
principle  of  treatment,  or  this  form  of  dressing  under  any  of  its  modi- 
tications.  Colles^  recommends  a  straight  palmar  and  dorsal  splint,  and 
does  not  incline  the  hand.  Barton^  advises  the  same,  and  Skej,  having 
declared  his  preference  for  a  couple  of  broad,  straight  splints,  adds : 
"  Great  care  should  be  taken  to  prevent  the  hand  falling,  and  this 
object  will  be  attained  by  inclosing  the  entire  forearm  and  hand  in  a 
well-applied  sling."^ 

Professor  Fauger,  of  Copenhagen,  has  undertaken  to  treat  this  frac- 
ture- in  some  sense  without  any  splint,  the  forearm  and  hand  being 
simply  laid  over  a  double  inclined  plane,  so  as  to  bring  the  wrist  into 
a  state  of  forced  flexion.  "  The  hand  having  been  brought  into  a 
position  of  strong  flexion,  the  forearm  is  placed,  pronated,  on  an 
oblique  plane,  with  the  carpus  highest,  the  hand  being  permitted  to 
hang  freely  down  the  perpendicular  end  of  the  plane."*  M.  Velpeau, 
in  a  report  of  his  surgical  clinic  at  La  Charite  for  the  year  ending 
September,  1846,  says  this  plan  has  been  tried  during  the  year,  and 
*'  the  result  has  not  been  very  satisfactory.  The  experiment,  however, 
has  not  been  decisive  upon  this  mode  of  treatment."* 

Notwithstanding  these  exceptions,  the  practice  seems  to  be  pretty 
well  established  among  the  leading  surgeons  everywhere  to  employ  in 
the  treatment  of  this  fracture  the  principle  of  adduction  of  the  hand, 
and  always  to  the  attainment  of  the  same  purpose,  namely,  rotary 
extension,  by  which  they  hope  to  retain  more  securely  the  lower  frag- 
ment in  place. 

We  come  now  to  consider  how  far  this  peculiar  treatment  is  capa- 
ble of  answering  the  special  indications  of  the  case  we  are  studying. 

It  is  assumed,  as  I  have  already  intimated,  that,  by  bearing  the 
hand  strongly  to  the  ulnar  side,  the  fragments  of  the  radius  are 
brought  more  exactly  into  apposition,  and  more  easily  and  effectually 
retained ;  an  assumption  which  supposes  two  things    to  have  been 

1  CoUes,  Lectures  on  Surgery,  p.  325.         ^  Barton,  Phil.  Med.  Exam.,  1838. 

^  Skey,  Operative  Surgery,  p.  161.  ''  Fauger,  London  Lancet,  May  8, 1847. 

*  Velpeau,  Boston  Med.  Jouru.,  vol.  xxxv.  p.  213. 


I  COLLES'    FEACTURE.  285 

jiletermined ;  first,  that  there  exists  an  overlapping  of  the  fragments, 
jsither  through  the  whole  extent  of  their  broken  surfaces  or  especially 
l:invard  the  radial  side,  or  that  the  upper  end  of  the  lower  fragment 
IS  inclined  to  fall  against  the  ulna,  or  that  all  of  these  several  condi- 
tions coexist ;  and,  secondly,  that  if  such  displacements  do  exist,  they 
can  be  remedied  by  this  manoeuvre. 

The  first  of  these  suppositions  seems  to  have  been  sufficiently  con- 
,3idered  and  fully  controverted  by  all  those  gentlemen  who  have  par- 
|ticularly  examined  the  specimens  contained  in  the  various  pathologi- 
cal collections,  and  to  whose  careful  investigations  I  have  already 
frequently  adverted.  My  own  observation  confirms  also  their  state- 
ments. With  rare  exceptions,  none  of  these  displacements  have  been 
found  to  exist,  although,  as  has  been  observed,  a  casual  inspection  of 
tlie  arm  when  recently  broken  would  often  lead  to  an  opposite  con- 
clusion. 

In  regard  to  the  second  supposition,  namely,  that  where  such 
displacements  do  exist,  a  forced  adduction  will  aid  in  the  retention  of 
the  fragments,  I  shall  have  to  speak  more  cautiously,  because,  so  far  as 
I  know,  my  opinions  have  received  as  yet  no  public  and  authoritative 
indorsement.  In  order  that  adduction  may  prove  effective,  there  must 
be  some  point  upon  which  to  act  as  a  fulcrum.  It  is  of  no  use  that  we 
rotate  the  hand  for  the  purpose  of  making  extension  unless  there  can 
be  found  a  resistance  or  limit  to  the  rotary  motion.  Such  a  limit 
exists,  no  doubt,  but  to  determine  its  availability  we  must  ascertain  its 
character  and  position. 

It  is  not  in  the  lower  end  of  the  ulna,  for  the  ulna  has  no  point  of 
contact  with  the  carpal  bones,  and  when,  in  the  natural  state  of  these 
parts,  the  hand  is  inclined  to  the  ulnar  side,  the  lower  end  of  the  ulna 
rides  freely  downwards  upon  the  wrist  until  arrested  by  the  ligaments 
which  unite  it  with  the  carpus,  and  by  the  capacity  of  the  joint  to 
move  in  this  direction.  When  the  lower  end  of  the  radius  is  broken, 
and  the  ligaments  of  the  joint  more  or  less  torn,  the  ulna,  although 
thrust  downwards  much  further  than  it  could  ever  descend  in  its 
normal  state,  still  fails  to  find  a  support,  and  spreading  wider  and 
wider  from  the  radius  as  it  is  thrust  further  upon  the  hand,  no  limit 
can  be  given  to  its  progress  in  this  direction.  It  was  thus  that,  in  one 
example  already  mentioned,  I  found  the  ulna  carried  downwards  one 
inch  or  more. 

If  the  fragments  overlap  each  other  in  their  entire  diameter,  it  is 
very  certain  then  that  a  fulcrum  could  not  be  obtained  upon  any  point 
of  their  broken  surfaces;  and  if  the  fracture  is  transverse  in  its  antero- 
posterior diameter,  and  transverse,  or  only  slightly  oblique,  in  its 
lateral  diameter,  when  once  replaced,  the  surfaces  must  of  necessity 
support  themselves,  and  the  indication  in  question  cannot  be  present. 
If,  again,  the  direction  of  the  fracture  is  from  before  backwards  and 
oblique,  and  reduction  has  been  effected,  no  chance  still  remains  to 
prevent  the  sliding  off"  of  the  radial  edge,  if  it  is  disposed  to  happen, 
by  making  use  of  the  ulnar  extremity  of  the  broken  surface  as  a 
fulcrum.  If  the  radial  side  is  inclined  to  fall  off",  what  shall  prevent 
the  ulnar  from  doing  the  same?    And  how  then  can  it,  the  ulnar  side, 


286  FEACTUEES    OF   THE   EADIUS. 

be  used  as  a  fulcrum  ?  It  only  remains  to  suppose  an  impaction  of 
the  radial  margin  of  the  broken  radius  without  similar  impaction  of 
the  ulnar  margin,  or  a  fracture  extending  very  obliquely  from  the 
radial  margin  into  the  joint,  as  the  sole  examples  in  which  the  lower 
fragment  can  find  a  sufficient  fulcrum  upon  which  the  rotary  extension 
may  operate.  The  first  of  these  examples  I  have  supposed  without 
being  aware  of  the  proof  of  its  existence,  and  the  second  is  probably 
rare. 

I  have  not  spoken  of  the  ligaments  which  bind  the  lower  fragment 
to  the  lower  end  of  the  ulna,  and  the  ulna  to  the  carpal  bones,  viz : 
the  radio-ulnar,  and  the  internal  lateral  ligaments,  which  in  the  normal 
state  of  the  parts  constitute  the  centre  upon  which  forced  adduction 
expends  its  power,  and  which  still  continue  to  be  the  point  of  resist- 
ance when  the  radius  is  broken.  And  this  brings  me  to  the  point 
and  purpose  of  my  inquiry.  How  feeble  and  uncertain  must  be  a 
resistance  which  depends  solely  on  these  broken  ligaments !  And 
how  painful  to  the  patient  must  be  an  extension  sufficient  to  overcome 
the  action  of  nearly  all  the  muscles  of  the  wrist,  which  is  borne  en- 
tirely by  a  few  lacerated  and  inflamed  fibres !  even  in  health  this 
position,  when  forced,  cannot  be  endured  beyond  a  few  seconds,  and  it 
must  be  difficult  to  estimate  the  sufferings  which  the  same  position 
must  occasion  when  the  ligaments  are  torn  and  inflamed. 

I  am  not  to  be  told  that  surgeons  have  not  intended  to  teach  this 
extreme  practice;  that  they  have  never  recommended  forced  adduction, 
but  only  a  moderate  and  easy  lateral  inclination,  such  as  can  be  com- 
fortably borne.  If  they  have  not,  then  they  should  not  have  spoken 
of  making  extension  by  this  means.  An  easy  lateral  inclination  has 
no  power  to  do  good  so  far  as  extension  is  concerned,  any  more  than 
it  has  power  to  do  harm.  But  the  fact  is,  while  a  majority  of  surgeons 
have  no  doubt  used  less  force  than  was  hurtful,  some  have  used  more 
than  was  useful  or  safe;  indeed,  the  sharpness  of  the  curve  given  to 
the  splints  figured  and  recommended  by  Dupuytren,  Nelaton,  and 
others,  sufficiently  indicate  that  their  distinguished  inventors  intended 
to  accomplish  by  these  means  a  forced  and  violent  adduction. 

Malgaigne,  speaking  of  other  means  of  extension  applied  to  the 
forearm,  suggested  by  Godin,  Diday,  and  Velpeau,  intended  to  operate 
only  in  a  straight  line,  and  alluding  especially  to  the  modes  devised 
by  Huguier  and  Velpeau,  remarks :  "  Without  discussing  here,  the 
comparative  value  of  the  two  appareils,  I  believe  that  they  could 
scarcely  be  endured  by  the  patients ;  and  M.  Diday  tells  us  that  in 
the  trials  which  he  has  made,  the  pain  produced  by  the  extension  was 
so  great  that  he  was  compelled  to  renounce  it."  Which  observations 
cannot  but  apply  equally  to  this  plan  of  extension  by  adduction,  or 
to  any  other  which  might  be  adopted. 

After  all,  it  must  not  be  inferred  that  I  have  concluded  to  reject 
this  mode  of  dressing  in  all  of  its  modifications ;  for  although  I  am  far 
from  being  persuaded  of  its  utility  as  a  means  of  extension  and  re- 
tention in  any  case,  yet  I  am  not  prepared  to  deny  to  it  some  very 
considerable  value  in  another  point  of  view;  and  when  judiciously 
employed  it  can  certainly  do  no  harm.     It  is,  I  repeat,  for  another 


COLLES'   FRACTURE.  287 

reason  altogether  than  the  one  heretofore  assigned,  that  I  would  re- 
commend its  continuance,  a  reason  which  I  cannot  so  well  explain,  or 
hope  to  render  intelligible,  except  to  the  practical  surgeon.  This 
position  throws  the  whole  lower  end  of  both  radius  and  ulna  outwards 
toward  the  radial  margin  of  the  splints,  and  by  keeping  the  radius 
more  completely  in  view,  it  enables  the  surgeon  better  to  judge  of  the 
accuracy  of  the  reduction,  and  to  recognize  more  readily  the  condition 
and  situation  of  the  compresses,  etc.  This  alone  1  have  always  con- 
sidered a  sufficient  ground  for  retaining  the  angular  splint;  although 
I  have  treated  a  number  of  arms  satisfactorily  with  the  straight  splints 
alone. 

Finally,  while  surgeons  have  been  seeking  to  accomplish  an  indica- 
tion, the  existence  of  which  is  at  least  rendered  doubtful,  and  by  means 
which  appear  to  me  totally  inadequate,  if  it  did  exist,  they  have  proba- 
bly too  often  overlooked  or  regarded  indifferently  an  indication  which 
is  almost  uniformly  present,  namely,  to  press  forwards  the  tilted  frag- 
ment by  a  force  applied  upon  the  wrist  from  behind,  and  to  retain  it 
in  place  by  suitable  compresses.  And  I  cannot  help  thinking  that  if 
they  had  regarded  this  as  the  sole  indication,  an  indication  generally 
so  easily  accomplished,  they  would  have  made  fewer  crooked  arms, 
and  have  saved  their  patients  much  suffering  and  themselves  much 
trouble. 

It  only  remains  for  us  to  determine  the  precise  form  of  splint  which 
ought  to  be  preferred,  and  to  describe  its  mode  of  application. 

The  narrow  "attelle  cubitale"  of  Dupuytren,  is  inconvenient;  nor 
can  I  give  the  preference  to  the  curved  dorsal  splint  recommended  by 
Nelaton,  and  employed  by  Kobert  Smith,  Erichsen,  and  others.  It  is 
not  to  me  a  matter  of  entire  indifference,  in  case  only  one  curved  splint 
is  employed,  whether  this  be  applied  to  the  palmar  or  dorsal  surfaces 
of  the  forearm.  Foreign  surgeons,  so  far  as  I  know,  have  applied  this 
splint  to  the  dorsal  surface,  and  the  straight  splint  to  the  palmar; 
while  American  surgeons  have  adopted  almost  as  uniformly  the  oppo- 
site rule — to  whose  practice,  in  this  respect,  I  acknowledge  myself 
also  partial.  It  is  to  the  curved  splint  rather  than  to  the  straight, 
that  we  mainly  trust;  not  simply,  or  at  all,  perhaps,  because  of  its  form, 
but  because  the  curved  splint  is  also  the  long  splint.  This  is  the 
splint,  therefore,  which  ought  to  be  the  most  steady  and  immovable 
in  its  position.  Now,  the  very  irregularities  of  surface  upon  the 
palmar  aspect  of  the  forearm  and  band,  instead  of  constituting  an 
embarrassment,  enable  us,  when  the  splint  is  suitably  prepared  and 
adjusted,  to  fix  it  more  securely.  Moreover,  upon  it  alone,  after  a 
few  days,  the  surgeon  may  see  fit  to  rely,  and  in  that  case  it  ought  to 
be  applied  to  that  surface  of  the  arm  which  is  most  tolerant  of  con- 
tinued pressure.  The  palmar  surface,  as  being  more  muscular,  and 
as  having  been  more  accustomed  to  friction  and  to  pressure,  must 
necessarily  have  the  advantage  in  this  respect.  The  palmar  splint  ter- 
minating also  at  the  metacarpo-phalangeal  articulations,  instead  of  at  the 
wrist,  as  the  short  straight  splint  must  do  when  the  hand  is  adducted, 
enables  the  hand  to  be  flexed  upon  its  extremity  over  a  hand-block, 
or  pad  of  proper  size.      Such  are  the  not  insignificant  advantages 


288  FRACTURES  OF  THE  RADIUS. 

which  we  claim  for  this  mode,  over  that  pursued  by  our  transatlantic 
brethren. 

The  block  suggested  first  by  Bond,  of  Philadelphia,  is  a  valuable  addi- 
tion; since  the  flexed  position  is  always  more  easy  for  the  fingers,  and 
in  case  of  anchylosis  this  position  renders  the  whole  hand  more  useful. 
For  myself,  I  am  in  the  habit  of  preparing  extemporaneously  a  splint 
from  a  wooden  shingle,  which  I  first  cut  into  the  requisite  shape 
and  length  ;  the  length  being  obtained  by  measuring  from  the  front 
of  the  elbow -joint,  when  the  arm  is  flexed  to  a  right  angle,  to  the 
metacarpo-phalangeal  articulations.  It  ought,  indeed,  to  fall  half  an 
inch  short  of  the  bend  of  the  elbow,  to  render  it  certain  that  it  shall 
make  no  uncomfortable  pressure  at  this  point;  and  the  direction  to 
measure  with  the  arm  flexed,  is  of  sufficient  importance  to  warrant  a. 

repetition.     The  breadth  of  the  splint 
s-  °'-  should  be  in  all  its  extent  just  equal 

to  the  breadth  of  the  forearm  in  its 
widest  part,  so  that  there  shall  be  no 
lateral  pressure  upon  the  bones.  If 
the  splint  is  of  unequal  breadth,  the 
The  author's  splint.  Tollcr  cauuot  bc  SO  neatly  applied,  and 

it  is  more  likely  to  become  disarranged. 
Thus  constructed  it  is  to  be  covered  with  a  sack  of  cotton  cloth,  made 
to  fit  tightly,  with  the  seam  along  its  back ;  and  afterwards  stuffed  with 
cotton  batting  or  with  curled  hair.  These  materials  may  be  passed 
in  and  easily  adjusted,  wherever  they  are  most  needed,  from  the  open 
extremities  of  the  sack.  While  preparing,  the  splint  must  be  occasion- 
ally applied  to  the  arm  until  it  fits  accurately  every  part  of  the 
forearm  and  hand,  only  that  the  stuffing  must  be  rather  more  firm 
a  little  above  the  lower  end  of  the  upper  fragment.  The  open  ends 
of  the  sack  are  then  to  be  neatly  stitched  over  the  ends  of  the  splint. 
This  splint  is  now  to  be  laid  directly  upon  the  skin  without  any  inter- 
mediate compresses  or  rollers. 

The  advantages  of  this  form  of  splint  are  easily  comprehended. 
They  consist  in  facility  and  cheapness  of  construction,  accuracy  of 
adaptation,  neatness,  permanency  and  fitness  to  the  ends  proposed. 

The  extemporaneous  splint  recommended  by  Dr.  Isaac  Hays,  of 
Philadelphia,  is  very  similar,  but  it  lacks  the  neatness  and  permanency 
of  that  which  I  have  now  described. 

In  all  cases  it  is  better  to  employ,  also,  at  least  during  the  first  fort- 
night, a  straight  dorsal  splint,  of  the  same  breadth  as  the  palmar  splint, 
and  of  sufficient  length  to  extend  from  the  elbow  to  the  middle  of 
the  metacarpus.  This  should  be  covered  and  stuffed  in  the  same 
manner  as  the  palmar  splint,  except  that  here  the  thickest  and  firmest 
part  of  the  splint  must  be  opposite  the  carpus  and  the  lower  end  of 
the  lower  fragment.  It  will  answer  the  indications  also  a  little  more 
completely  if,  at  this  point,  the  padding  is  thicker  on  the  radial  than 
on  the  ulnar  side. 

Having  restored  the  fragments  to  place,  in  case  of  Colles'  fracture, 
by  pressing  forcibly  upon  the  back  of  the  lower  fragment,  the  force 
being  applied  near  the  styloid  apophysis  of  the  radius,  the  arm  is  to 


FEACTURES  OF  THE  RADIUS. 


289 


Fig.  88. 


be  flexed  upon  the  body  and  placed  in  a  position  of  semi-pronation; 
when  the  splints  are  to  be  applied  and  secured  with  a  sufficient  num- 
ber of  turns  of  the  roller,  taking 
especial  care  not  to  include  the 
thumb,  the  forcible  confinement 
of  which  is  always  painful  and 
never  useful. 

I  cannot  too  severely  reprobate 
the  practice  of  violent  extension  of 
the  wrist  in  the  efforts  at  reduction, 
and  that,  whether  this  extension 
be  applied  in  a  straight  line,  or 
with  the  hand  adducted.  It  has 
been  shown  that  in  a  great  major- 
ity of  cases  no  indication  in  this 
direction  is  to  be  accomplished, 
and  to  pull  violently  upon  the 
wrist  is  not  only  useless  but  hurt- 
ful. It  is  adding  to  the  fracture, 
and  to  the  other  injuries  already 
received,  the  graver  pathological 
lesion  of  a  stretching,  a  sprain,  of 
all  the  ligaments  connected  with 
the  joint.  I  am  persuaded  that  to 
this  violence,  added  to  the  unequal 
and  too  firm  pressure  of  the  splints, 
are,  in  a  great  measure,  to  be 
attributed  the  subsequent  inflam- 
mation and  anchylosis,  in  very 
many  cases. 

The  first  application  of  the  bandages  ought  to  be  only  moderately 
tight,  and  as  the  inflammation  and  swelling  develop  in  these  struc? 
tures  with  rapidity,  they  should  be  attentively  watched  and  loosened 
as  soon  as  they  become  painful.  It  must  be  constantly  borne  in  mind 
that,  to  prevent  and  control  inflammation,  in  this  fracture,  is  the  most 
difficult  and  by  far  the  most  important  object  to  be  accomplished, 
while  to  retain  the  fragments  in  place  when  once  reduced,  is  compara- 
tively easy  and  unimportant. 

During  the  first  seven  or  ten  days,  therefore,  these  cases  demand 
the  most  assiduous  attention  ;  and  we  had  much  better  dispense  with 
the  splints  entirely  than  to  retain  them  at  the  risk  of  increasing  the 
inflammatory  action.  Indeed,  I  have  no  doubt  that  very  many  cases 
would  come  to  a  successful  termination  without  splints,  if  only  the 
hand  and  arm  were  kept  perfectly  still  in  a  suitable  position  until 
bony  union  was  effected. 

I  must  also  enter  my  protest  against  many  or  all  of  those  carved 
splints  which  are  manufactured,  hawked  about  the  country  and  sold 
by  mechanics,  who  are  not  surgeons ;  with  a  fossa  for  each  styloid 
process,  a  ridge  to  press  between  the  bones,  and  various  other  curious 
provisions  for  supposed  necessities,  but  which  never  find  in  any  arm 
19 


The  author's  dressing  complete.  The  curved 
palmar  splint  is  not  in  view,  only  the  dorsal.  The 
dotted  lines  represent  the  roller.  The  sling  is 
omitted  for  the  purpose  of  bringing  the  other  dress- 
ings into  view. 


290  FRACTUEES  OF  THE  RADIUS. 

their  exact  counterparts,  and  only  deceive  the  inexperienced  surgeon 
into  neglect  of  the  proper  means  for  making  a  suitable  adaptation. 
They  are  the  fruitful  sources  of  excoriations,  ulcerations,  inflamma- 
tions and  deformities. 

In  reference  to  the  treatment  of  these  fractures,  the  following  cases 
and  the  accompanying  remarks,  by  that  great  surgeon  Dupuytren,  are 
too  pertinent  not  to  merit  a  place  in  every  treatise  of  this  character. 

"  The  two  succeeding  cases  are  not  only  interesting  as  fractures  of 
the  radius,  but  they  are  further  deserving  of  attentive  consideration 
on  account  of  the  serious  complications  which  accompanied  them,  and 
which  were  the  consequence  of  forgetting  an  important  precept.  More 
than  once,  indeed,  it  has  occurred  that  the  surgeons  have  been  so  in- 
tent on  preserving  fractures  in  their  proper  position,  that  the  extreme 
constriction  employed  has  actually  caused  destruction  of  the  soft  parts. 
A  piece  of  advice  which  I  have  very  frequently  given,  and  which  I 
cannot  too  often  repeat  is,  to  avoid  tightening  too  much  the  apparatus 
for  fractures  during  the  first  few  days  of  its  being  worn;  for  the  swell- 
ing which  supervenes  is  always  accompanied  by  considerable  pain, 
and  may  be  followed  by  gangrene.  It  cannot  therefore  be  too  urgently 
impressed  on  young  practitioners,  to  pay  attention  to  the  complaints 
which  patients  make;  and  to  visit  them  twice  daily,  and  relax  the 
bandages  and  straps  as  need  may  be,  in  order  to  obviate  the  frightful 
consequences  which  may  spring  from  not  heeding  this  necessary  pre- 
caution :  by  carefully  attending  to  this  point  I  have  been  saved  the 
painful  alternative  of  ever  having  to  sacrifice  a  limb  for  complications 
which  its  neglect  may  entail. 

"  Antoine  Eilard,  set.  44,  fractured  his  right  radius  whilst  going 
down  into  a  cellar,  in  Feb.  1828,  and  went  at  once  to  the  Hospital  of 
La  Charite,  When  the  fracture  was  reduced  (it  was  near  the  base  of 
the  bone)  an  apparatus  was  applied,  but  fastened  too  tightly;  and, 
notwithstanding  the  great  swelling,  and  the  acute  pain  which  the 
patient  endured,  it  was  not  removed  until  the  fourth  day,  when  the 
hand  was  cold  and  oedernatous,  and  the  forearm  red,  painful,  and 
covered  with  vesications.  Leeches,  poultices,  and  fomentations  were 
applied,  and  followed  by  some  alleviation  of  the  local  symptoms, 
though  there  was  much  constitutional  disturbance.  At  the  close  of  a 
fortnight  from  the  accident,  the  palmar  surface  of  the  forearm  pre- 
sented a  point  where  fluctuation  was  supposed  to  exist ;  but  when  a 
bistoury  was  plunged  into  it  no  matter  followed.  Portions  of  the 
flexor  muscles  subsequently  sloughed,  and  the  skin  subsequently 
mortified.  The  only  resource  was  amputation,  which  was  performed 
above  the  elbow,  six  weeks  after  his  admission ;  and  he  afterwards 
recovered  without  the  occurrence  of  any  further  untoward  symptoms. 

"E.,  set.  36,  was  at  work  boring  an  artesian  well  in  1832,  when  he 
was  struck  by  a  part  of  the  machinery  on  the  right  forearm ;  he  was 
instantly  knocked  down  and  thrown  violently  on  the  right  thigh,  A 
surgeon  who  was  sent  for  detected  a  fracture  of  the  radius,  and  ap- 
plied the  usual  apparatus,  consisting  of  pads  and  splints,  confined  by 
a  roller  extending  from  the  extremities  of  the  fingers  to  the  elbow, 
which  compressed  the  arm  so  tightly  as  to  give  rise  to  very  great 


FRACTURES  OF  THE  RADIUS.  291 

suffering.  The  fingers,  hand,  and  forearm  were  numbed  almost  to 
insensibility,  and  yet  the  surgeon  in  attendance  did  not  think  proper 
to  loosen  the  apparatus.  Such  was  the  condition  of  the  patient  until 
he  came  to  the  Hotel  Dieu,  four  days  after  the  accident;  the  fingers 
were  then  black,  cold,  and  insensible,  and  when  I  removed  the  splints 
I  found  the  hand  likewise  black,  especially  on  its  palmar  surface. 
The  lower  part  of  the  forearm  was  a  shade  less  livid,  but  equally  cold 
and  insensible ;  and  several  vesicles  filled  with  pink-colored  serum 
were  apparent  on  both  its  surfaces  where  the  splints  had  pressed ;  the 
upper  part  of  the  forearm  was  inflamed,  swollen,  and  very  painful. 
He  was  bled  and  leeches  were  applied  to  the  inflamed  part  of  the  arm ; 
camphorated  spirit  was  applied  to  the  fingers. 

"  On  the  following  day  heat  was  restored  as  low  as  the  wrist,  but 
the  hand  remained  for  the  most  part  livid  and  cold,  and  the  radial 
artery  did  not  pulsate.  Seventy  leeches  were  applied  to  the  forearm, 
and  the  local  application  was  continued."  On  the  second  day  after 
admission  thirty  more  leeches  were  applied.  On  the  fourth  day  the 
hand  looked  a  little  better,  so  as  to  "  encourage  some  hope  of  its  being 
saved ;  but  this  was  again  blighted  on  the  sixth  day,  by  the  entire  loss 
of  heat  and  sensibility  in  the  part,  and  increased  pain  and  swelling  in 
the  forearm,  to  which  the  gangrene  subsequently  extended.  On  the 
twelfth  day  amputation  was  performed  at  the  elbow-joint;  but  the 
patient  did  not  survive  the  operation  more  than  ten  days,  the  immedi- 
ate cause  of  death  being  acute  pleurisy.  There  was  a  considerable 
quantity  of  purulent  serosity  poured  out  on  the  right  side  of  the  chest; 
and  abscesses  were  found  in  the  lungs  and  liver.  On  examining  the 
arm,  there  was  found  to  be  a  simple  fracture  of  the  radius  about  its 
centre. 

"  The  above  case  presents  a  painful  illustration  of  the  neglect  to 
which  I  have  alluded.  In  nearly  every  instance  the  swelling  of  the 
limb  requires  that  careful  attention  should  be  paid  to  the  bandage  or 
straps,  by  which  the  apparatus  is  confined.  Similar  accidents  are  likely 
to  result  from  the  employment  of  an  immovable  apparatus,  of  which 
an  example  occurred  in  the  practice  of  M.  Thiery,  one  of  my  pupils. 
He  was  summoned  to  visit  a  young  girl,  on  whom  such  an  apparatus 
had  been  applied  for  supposed  fracture  of  the  radius.  After  suffering 
excruciating  torment,  the  forearm  mortified,  and  amputation  was  the 
only  resource;  on  examining  the  limb  no  trace  of  fracture  could  be  dis- 
covered. Had  a  simple  apparatus  been  here  employed,  and  properly 
watched,  this  patient's  limb  would  not  have  been  sacrificed."^ 

Kobert  Smith,  mentions  also  the  case  of  a  boy,  get.  18,  who  had  a 
fracture  of  the  lower  extremity  of  the  radius,  through  the  line  of  the 
junction  of  the  epiphysis  with  the  diaphysis,  caused  by  being  thrown 
from  a  horse.  A  surgeon  applied  within  an  hour,  a  narrow  roller 
tightly  around  the  wrist.  On  the  following  day  the  limb  was  in- 
tensely painful,  cold  and  discolored  ;  still  the  roller  was  not  removed, 
nor  even  slackened.  On  the  fourth  day  he  was  admitted  into  the  Rich- 
mond Hospital,  when  the  gangrene  had  reached  the  forearm.     Spon- 

'  Dupuytren,  Injuries  and  Diseases  of  Bones,  Syd.  ed.,  London,  1847,  pp.  145-7. 


292  FRACTURES    OF    THE    RADIUS. 

taneous  separation  of  the  soft  parts  finally  occurred,  and  the  bones 
were  sawn  through  twenty-four  days  after  the  fracture  was  produced, 
from  which  time  "  everything  proceeded  favorably ."'^ 

Nov,  21,  1851,  a  boy  ten  years  old,  living  in  the  town  of  Andover, 
Mass.,  had  his  left  hand  drawn  into  the  picker  of  a  woollen  mill,  pro- 
ducing several  severe  wounds  of  the  hand  and  a  fracture  of  the  radius 
near  its  middle.  One  of  the  wounds  was  situated  directly  over  the 
point  of  fracture,  but  whether  it  communicated  with  the  bone  or  not 
was  not  ascertained.  A  surgeon  was  called,  who  closed  the  wounds, 
covered  the  forearm  with  a  bandage  from  the  hand  to  above  the  elbow, 
and  applied  compresses  and  splints.  This  lad  made  no  complaint, 
his  appetite  remaining  good  and  his  sleep  continuing  undisturbed, 
until  the  third  day,  when  he  began  to  speak  of  a  pain  in  his  shoulder; 
on  the  same  day  also  it  was  noticed  that  his  hand  was  rather  insensi- 
ble to  the  prick  of  a  pin.  Early  on  the  morning  of  the  fourth  day 
his  surgeon  being  summoned,  found  him  suffering  more  pain  and 
quite  restless;  and  on  removing  the  dressings,  the  arm  was  discovered 
to  be  insensible  and  actually  mortified  from  the  shoulder  downwards. 

Opiates  and  cordials  were  immediately  given  to  sustain  the  patient, 
and  fomentations  ordered. 

On  the  sixth  day  a  line  of  demarcation  commenced  across  the  shoul- 
der, and  on  the  twentj^-first  day,  the  father  himself  removed  the  arm 
from  the  body  by  merely  separating  the  dead  tissues  with  a  feather. 
Subsequently  a  surgeon  found  the  head  of  the  humerus  remaining  in 
the  socket,  and  removed  it,  the  epiphysis  having  become  separated 
from  the  diaphysis.     The  boy  now  rapidly  got  well. 

In  the  year  1853,  this  case  became  the  subject  of  a  legal  investiga- 
tion, in  the  course  of  which  Dr.  Pilsbury,  of  Lowell,  Mass.,  declared 
that  in  his  opinion  this  unfortunate  result  had  been  caused  by  too  tight 
bandaging,  and  by  neglecting  to  examine  the  arm  during  four  days. 

On  the  other  hand,  Drs.  Hayward,  Bigelow,  Townsend,  and  Ains- 
worth,  of  Boston,  with  Kimball,  of  Lowell,  Drs.  Loring,  and  Pierce,  of 
Salem,  believed  that  the  death  of  the  limb  was  due  to  some  injury 
done  to  the  artery  near  the  shoulder-joint ;  and  in  no  other  way  could 
they  explain  the  total  absence  of  pain  during  the  first  two  days;  nor 
could  they  regard  this  condition  as  consistent  with  the  supposition 
that  the  bandage  occasioned  the  death  of  the  limb.^ 

I  cannot  but  think,  however,  that  these  gentlemen  were  mistaken, 
and  that  the  gangrene  was  alone  due  to  the  bandages.  In  a  similar 
case  which  came  under  my  own  observation,  and  in  which  both  the 
radius  and  ulna  were  broken,  the  roller  extended  no  higher  than  just 
above  the  elbow,  and  the  patient  complained  of  no  pain  until  the 
bandages  were  unloosed,  yet  the  arm  separated  at  the  shoulder-joint. 
I  shall  refer  again  to  this  example  in  the  chapter  on  fractures  of  the 
radius  and  ulna;  and  I  shall  take  occasion  then  also  to  speak  more 
fully  of  the  causes  of  these  terrible  accidents. 

Norris  mentions  another  case  of  compound  fracture  of  the  lower 

'  R.  Smith,  Treatise  on  Fractures,  &c.,  Dublin,  1854,  p.  170. 
^  Bost.  Med.  and  Surg.  Journ.,  vol.  xlviii.  p.  281. 


FRACTUEES  OF  THE  EADIUS.  293 

end  of  the  radius  which  came  under  his  notice  at  the  Pennsylvania 
Hospital,  in  August,  1887,  the  arm  having  been  dressed  by  a  country 
surgeon  within  half  an  hour  after  the  accident,  with  bandages  and 
splints.  When  these  bandages  were  removed  at  the  hospital,  on  the 
fifth  day,  "the  soft  parts  around  the  fracture  were  found  to  have 
sloughed,  an  abscess  extended  up  to  the  elbow-joint,  and  sloughs 
existed  over  the  condyles.  Severe  constitutional  symptoms  arose, 
making  amputation  of  the  arm  necessary."^ 

A  lady,  ^et.  50,  was  also  seen  by  Thierry,  who,  having  broken  the 
radius  near  its  lower  end,  lost  her  fingers  by  the  sloughing  consequent 
upon  a  tight  bandage.^ 

The  remarks  which  have  now  been  made  in  relation  to  the  treatment 
of  Colles'  fracture,  are  applicable,  with  only  such  slight  modifications 
as  would  naturally  be  suggested,  to  fractures  of  the  lower  end  of  the 
radius  commencing  upon  the  radial  side  of  the  bone  and  extending 
obliquely  downwards  into  the  joint ;  and  it  is  to  this  form  of  fracture 
especially,  that  the  pistol-shaped  splint  must  be  found  applicable.  If 
the  fracture  actually  extends  into  the  joint,  it  is  even  the  more  neces- 
sary that,  in  order  to  the  prevention  of  anchylosis,  the  wrist  should  be 
early  subjected  to  passive  motion. 

The  following  example  of  a  compound,  comminuted  fracture  of  the 
radius,  may  serve  to  illustrate  the  value  of  a  somewhat  novel  mode 
of  treatment  under  certain  circumstances : — 

William  Croak,  of  Buffalo,  set.  30.  Jan.  29,  1856,  a  large  piece  of 
iron  casting  fell  upon  his  arm,  crushing  and  lacerating  the  wrist,  and 
comminuting  the  lower  part  of  the  radius;  he  was  immediately  taken 
to  the  Hospital  of  the  Sisters  of  Charity,  I  found  the  whole  of  the 
soft  parts  torn  away  in  front  of  the  joint,  and  the  fragments  of  the 
radius  projected  into  the  flesh  in  every  direction.  The  hope  of  saving 
the  hand  seemed  to  be  scarcely  sufficient  to  warrant  the  attempt;  at 
least  by  the  ordinary  mode  of  procedure.  I,  however,  stated  to  the 
gentlemen  present,  among  whom  were  Dr.  Rochester,  my  colleague, 
and  the  house  surgeon.  Dr.  Lemon,  that  I  believed  it  could  be  saved 
if,  having  removed  the  fragments  of  the  radius,  we  practised  resection 
of  the  lower  end  of  the  ulna,  and  allowed  the  muscles  to  become  com- 
pletely relaxed.  Accordingly,  after  placing  my  patient  under  the 
influence  of  chloroform,  I  enlarged  the  wounds  so  as  to  enable  me  to 
remove  six  or  seven  fragments  of  the  radius,  leaving  others  which 
were  broken  off  but  not  much  displaced.  I  then  removed  with  the 
saw  one  inch  and  a  half  of  the  lower  end  of  the  ulna.  The  hand  was 
immediately  drawn  up  by  the  contraction  of  the  remaining  muscles, 
but  their  tension  was  completely  relieved. 

The  wounds  were  closed  and  dressed  lightly,  and  the  whole  limb 
was  placed  on  a  broad  and  well-padded  splint  covered  with  oiled  cloth. 
The  hand,  which  was  very  pale  and  exsanguine,  was  covered  with 
warm  cotton  batting. 

The  subsequent  treatment  was  changed  from  time  to  time  to  suit 

'  Norris,  note  to  Liston's  Surgery,  p.  54. 

^  Amer.  Journ.  Med.  Sci.,  vol.  xxv.  p.  461,  from  L'Experience  for  1838. 


294 


FEACTURES    OF    THE    ULNA. 


the  indications;  but  his  recovery  was  rapid  and  complete,  nor  was 
there  at  any  time  excessive  inflammation  in  any  part  of  the  limb. 

I  have  seen  this  man  frequently  since  he  left  the  hospital,  and  while 
he  has  recovered  only  a  little  motion  in  the  wrist-joint,  his  hand  and 
fingers  are  nearly  as  useful  as  before  the  accident.  He  is  able  to  per- 
form all  ordinary  kinds  of  labor  with  almost  as  much  ease  as  most 
other  men ;  and  what  is  always  gratifying  to  the  humane  surgeon,  he 
does  not  fail  to  appreciate  fully  the  service  which  has  been  conferred 
upon  him  by  the  preservation  of  his  somewhat  mutilated  hand. 


CHAPTEE    XXII 


FRACTURES   OF  THE  ULNA. 


§  1.  Shaft  of  the  Ulna. 

Causes. — The  shaft  of  the  ulna  is  generally  broken  by  a   direct 
blow.     I  have  never  seen  an  exception  to  this  rule  ;  but  Voisin  has 
related  in  the   Gazette  Medicale  for  1883,  a  single  example  in  which  it 
was  said  to  have  been  broken  by  a  fall  upon  the  palm  of  the  hand. 
Malgaigne  thinks  it  is  most   often  broken   when  one 
Fig.  89.         seeks  to  ward  off  a  blow  with  the  arm  ;  but  it  has  hap- 
pened most  often  to  me  to  see  it  broken  by  a  fall  upon 
the  side  of  the  arm. 

Point  of  Fracture,  Direction  of  Displacement,  &c. — In 
an  analysis  of  twenty-three  cases,  I  find  the  shaft  has 
|\^  been  broken  seven  times  in  its  upper  third,  eight  times 
in  its  middle  third,  and  eight  times  in  its  lower  third. 
All  portions  seem,  therefore,  to  be  about  equally  liable 
to  fracture.  I  think,  also,  the  fractures  have  generally 
been  oblique. 

Contrary  to  what  has  been  observed  by  other  writers, 
I  have  noticed  that  no  law  prevailed  as  to  the  direction 
in  which  the  fragments  have  become  displaced  ;  the 
broken  ends  being  found  directed  forwards,  backwards, 
inwards,  or  outwards,  according  to  the  direction  of  the 
blow  which  has  occasioned  the  fracture ;  and  this  is  in 
accordance  with  the  general  rule  in  other  fractures 
occasioned  by  direct  blows.  No  doubt,  however,  other 
things  being  equal,  the  tendency  of  the  lower  fragment 
would  be  toward  the  interosseous  space,  in  consequence 
of  the  action  of  the  pronator  quadratus  in  this  direction. 
Fracture  of  the  ^ud  if  the  fracturc  is  above  the  middle,  the  pronator  radii 
shaft  of  the  ulna,     tcrcs  also  will  increase  this  tendency  ;  while  the  upper 


SHAFT    OF    THE    ULNA.  295 

! 

'  fragment,  owing  to  its  broad  and  firm  articulation  at  the  elbow-joint,  can 
only  be  displaced  forwards  or  backwards,  at  least  to  any  great  extent. 

Complications. — In  no  case  of  the  shaft  of  a  long  bone  have  I  found 
serious  complications  so  frequent  as  in  fractures  of  the  shaft  of  the 
ulna.  Three  have  been  compound  ;  seven  complicated  with  a  forward 
dislocation  of  the  head  of  the  radius ;  one  with  a  partial  dislocation  of 
the  lower  end  of  the  radius  backwards,  and  one  with  a  dislocation  of 
both  radius  and  ulna  backwards  at  the  elbow-joint.  It  will  be  seen, 
therefore,  that  twelve,  or  more  than  one-half  of  the  whole  number, 
have  been  seriously  complicated. 

Symptoms. — Occasionally  this  fracture  is  found  to  exist  without 
sensible  displacement.  In  such  cases  the  diagnosis  is  sometimes  diffi- 
cult, and  can  only  be  determined  by  the  crepitus  and  mobility.  If,  how- 
ever, the  ulna  is  firmly  seized  above  and  below  the  point  which  has 
suffered  contusion,  and  pressed  in  opposite  directions,  these  signs  will 
generally  be  sufficiently  manifest,  and  will  render  the  diagnosis  certain. 

But  in  cases  where  there  is  considerable  displacement,  the  inner 
surface  of  the  bone  is  so  superficial  as  to  enable  us  to  detect  its  devia- 
tions with  the  eye  alone,  or,  when  swelling  has  already  occurred,  by 
the  fingers  carried  firmly  and  slowly  along  this  margin. 

If  the  head  of  the  radius  is  dislocated  also,  the  displacement  of  the 
broken  ends  of  the  ulna  must  always  be  considerable,  and  the  con- 
sequent deformity  palpable.  I  have  known  one  instance,  however, 
in  which  a  surgeon  living  in  the  neighboring  Province  of  Upper 
Canada,  recognized  and  reduced  a  dislocation  of  the  radius  and  ulna 
backwards,  but  did  not  detect  a  fracture  of  the  ulna  two  inches  above 
its  lower  end.  Six  months  after,  in  the  month  of  March,  1856,  the 
patient  called  upon  me  with  a  marked  deformity  near  the  wrist,  occa- 
sioned by  the  backward  projection  of  the  broken  ulna,  and  with  a 
complete  loss  of  the  power  of  supination.  It  will  not  surprise  us  that 
this  fracture  was  overlooked  when  we  learn  that  the  man  had  fallen 
fifty-five  feet. 

Prognosis. — In  simple  fractures  the  prognosis  is  generally  favorable, 
since  no  overlapping  can  occur,  and  the  lateral  displacements  are  not 
usually  sufficient  to  produce  a  marked  deformity,  or  to  interfere 
materially  with  the  functions  of  the  arm ;  yet  it  is  not  unfrequent  to 
find  the  fragments  inclining  slightly  forwards  or  backwards,  inwards 
or  outwards.  If  the  fragments  fall  toward  the  radius,  I  have  noticed 
in  three  or  four  instances  a  slight  projection  of  the  lower  end  or  sty- 
loid process  of  the  ulna  to  the  ulnar  side ;  but  not  interfering  in  any 
degree  with  the  motions  of  the  wrist-joint. 

I  have  seen  the  radius  left  unreduced  three  times  after  a  fracture  of 
the  ulna,  and  in  each  example  the  forearm  was  shortened.  A  boy,  ast, 
17,  was  struck  by  a  locomotive,  and  severely  injured  in  various  parts 
of  his  body,  June  5,  1855,  I  saw  him  with  two  very  intelligent  coun- 
try practitioners,  a  few  hours  after  the  accident.  The  whole  left  arm 
was  then  greatly  swollen.  Crepitus  was  distinct,  and  we  easily  recog- 
nized the  fracture  of  the  ulna  about  three  inches  below  its  upper  end, 
with  which  an  open  wound  was  in  direct  communication.  We  sus- 
pected, also,  a  dislocation  of  the  head  of  the  radius  forwards,  but  as  we 


296  FRACTURES    OF    THE    ULNA. 

could  not  make  ourselves  certain,  and  finding  that  the  arm  was  in 
such  a  condition  as  to  preclude  any  farther  manipulation  without 
greatly  diminishing  the  chance  of  saving  the  limb,  we  made  no  attempt 
at  reduction,  but  laid  the  arm  upon  a  pillow  and  directed  cool  water 
lotions. 

At  no  subsequent  period,  in  the  opinion  of  the  medical  gentleman 
who  was  left  in  charge,  did  a  favorable  opportunity  occur  to  reduce 
the  radius ;  and  at  the  end  of  two  months  I  found  the  ulna  united, 
with  the  fragments  bent  forwards  and  outwards  toward  the  radius, 
while  the  head  of  the  radius  lay  in  front  of  the  humerus.  The  forearm 
was  shortened  three-quarters  of  an  inch.  He  could  flex  his  arm  freely 
to  a  right  angle  and  a  little  beyond ;  and  he  could  straighten  it  per- 
fectly. Hand  slightly  proned,  with  partial  loss  of  supination.  Whole 
arm  nearly  as  strong  and  as  useful  as  before  the  accident.  Above  the 
olecranon  process,  on  the  back  of  the  humerus,  I  observed  a  remark- 
able fulness  occasioned  by  the  shortening  of  the  triceps  muscle. 

The  second  case  occurred  in  the  person  of  a  man  set.  26,  residing 
about  twenty  miles  from  town,  and  was  occasioned  by  the  kick  of  a 
horse.  This  was  also  a  compound  fracture.  It  does  not  appear  that 
his  surgeon  discovered  the  dislocation  of  the  radius,  but  supposed  that 
it  was  a  fracture  of  both  bones.  On  the  ninth  day  the  patient  became 
dissatisfied  and  dismissed  his  surgeon,  but  employed  no  other. 

Oct.  1,  1849,  eleven  weeks  after  the  accident,  he  called  upon  me  at 
Buffalo.  I  found  the  ulna  united  with  a  manifest  displacement,  but  I 
could  not  discover  that  there  had  been  any  fracture  of  the  radius. 
The  'head  of  the  radius  was  in  front  of  the  external  condyle,  and  a  de- 
pression existed  where  it  formerly  articulated.  When  the  arm  was 
flexed,  the  head  did  not  strike  the  humerus  so  as  to  arrest  the  flexion, 
but  it  glided  upwards  and  outwards  along  the  inclined  base  of  the  ex- 
ternal condyle.  He  had  already  begun  to  use  his  arm  considerably 
in  labor.     The  forearm  was  shortened  one  inch. 

The  third  example  was  in  the  person  of  John  Lewis,  of  Pa.,  set.  25, 
who  told  me,  in  Sept.  1851,  that  his  left  ulna  had  been  broken  two 
years  before,  and  at  several  points.  He  was  attended  by  two  surgeons 
living  at  Montrose,  Pa. 

I  found  the  ulna  much  bent  forwards  a  little  below  its  middle,  the 
head  of  the  radius  displaced  forwards,  and  the  forearm  shortened  one 
inch. 

Three  times  I  have  noticed  after  the  lapse  of  several  years  that  the 
forearm  could  not  be  perfectly  supined ;  but  pronation  was  never 
permanently  impaired.  I  think,  also,  that  the  motions  of  flexion  and 
extension  have  always,  except  where  the  radius  has  remained  dislo- 
cated, been  completely  restored  soon  after  the  splints  were  removed; 
and  even  in  these  latter  cases,  it  is  only  extreme  flexion  which  has 
been  hindered. 

Treatment. — In  simple  fracture  we  must  look  carefully  to  the  lateral 
deviation  of  the  fragments,  and  if  they  are  found  to  be  salient  forwards 
or  backwards,  pressure  made  directly  upon  or  near  their  extremities, 
restores  them  to  place,  but  it  often  requires  considerable  force  to  ac- 
complish this.     A  gentleman  fell  and  broke  the  right  ulna  near  its 


SHAFT    OF    THE    ULNA.  297 

middle.  He  came  immediately  to  me,  and  I  found  the  fragments  dis- 
placed backwards.  Pressing  strongly  with  my  fingers,  they  sprung 
forwards  with  a  distinct  crepitus,  and  I  thought  they  were  now  in 
exact  line.  A  broad  and  well-padded  splint  was  applied  to  the  fore- 
arm, and  I  took  especial  pains  with  compresses  nicely  adjusted,  from 
day  to  day,  to  keep  everything  in  place.  The  arm  was  placed  in  a 
sling.  Eight  months  after  the  accident  this  gentleman  died  of  cholera, 
and  I  was  permitted  to  dissect  the  arm,  I  found  the  fragments  well 
united,  but  with  a  very  palpable  projection  of  the  fragments  backwards, 
in  the  direction  in  which  they  were  at  first. 

If  the  displacement  is  in  the  direction  of  the  radius,  it  is  more  diffi- 
cult to  overcome,  but  its  necessity  is  much  more  urgent,  since  if  the 
fragments  fall  completely  against  the  radius,  a  bony  union  may  take 
place,  occasioning  a  complete  loss  of  the  power  of  pronation  and  of 
supination. 

While  moderate  extension  is  being  made,  and  the  hand  is  firmly 
supined,  the  fingers  of  the  surgeon  should  be  pressed  firmly,  and  in 
spite  sometimes  of  the  complaints  of  the  patient,  between  the  radius 
and  ulna,  and  the  fragments  of  the  broken  ulna  fairly  pushed  out  from 
the  radius. 

The  forearm  may  now  be  laid  in  the  usual  position  against  the  front 
of  the  chest,  midway  between  supination  and  pronation,  and  the  same 
splints  applied  and  in  the  manner  which  we  shall  hereafter  describe 
for  fractures  of  the  shaft  of  both  bones. 

We  ought,  however,  especially  to  bear  in  mind  the  danger  of  thrust- 
ing the  fragments  against  the  ulna,  by  allowing  the  sling  or  the  band- 
ao;es  to  rest  ao;ainst  the  middle  of  the  ulnar  side  of  the  bone.  To 
prevent  this,  the  sling  ought  to  support  the  arm  by  passing  only  under 
the  hand  and  wrist,  or  the  forearm  may  be  laid  in  a  firm  gutter  which 
will  touch  the  forearm  only  at  the  elbow  and  wrist,  or  it  may  be  laid 
upon  its  back  as  suggested  and  practised  by  Fleury,  who,  according 
to  Malgaigne,  had  a  case  which  had  been  treated  in  the  position  of 
semi-pronation,  and  which  remained  not  only  displaced  but  refused  to 
unite;  but  when  the  arm  was  supined,  the  fragments  came  at  once 
into  contact  and  bony  union  speedily  took  place.  This  position  may 
be  adopted  whenever  it  is  found  to  be  practicable ;  but  the  position  of 
demi-prouation  is  generally  much  more  comfortable  to  the  patient,  at 
least  when  the  forearm  is  laid  across  the  chest,  and  very  few  patients 
will  submit  to  a  position  of  complete  supination. 

In  fractures  accompanied  with  dislocation  of  the  head  of  the  radius 
forwards  or  backwards,  nothing  should  prevent  the  immediate  reduc- 
tion of  the  dislocation  but  a  demonstration  of  its  impossibility,  or  a 
condition  of  the  limb  which  would  render  manipulation  hazardous. 
It  can  be  reduced,  generally,  by  pushing  forcibly  upon  the  head  of  the 
bone  in  the  direction  of  the  socket,  while  the  arm  is  moderately  flexed 
so  as  to  relax  the  biceps,  and  while  extension  is  being  made  at  the 
forearm  by  an  assistant.  In  making  the  counter-extension,  care  should 
be  taken  to  seize  the  lower  end  of  the  humerus  by  the  condyles,  rather 
than  by  its  anterior  aspect,  by  which  precaution  we  shall  avoid  press- 
ing upon  and  rendering  tense  the  tendon  of  the  biceps. 


298  FRACTURES    OF    THE    ULNA. 

July  29,  1845,  a  lad,  get.  9,  fell  from  his  bed,  breaking  the  ulna 
and  dislocating  the  head  of  the  radius.  Dr.  Austin  Flint  was  called 
on  the  following  morning,  and  at  his  request  I  was  invited  to  see  the 
patient  with  him.  We  found  the  ulna  broken  obliquely  near  its  mid- 
dle, and  the  head  of  the  radius  dislocated  forwards.  While  Dr.  Flint 
seized  the  elbow  in  front  of  the  condyles,  I  made  extension  from  the 
hand,  the  forearm  being  slightly  flexed  upon  the  arm,  and  at  the  same 
moment  I  pushed  forcibly  the  head  of  the  radius  back  to  its  socket. 
The  reduction  was  accomplished  easily  and  completely. 

We  then  dressed  the  arm  with  Rose's  angular  splints,  constructed 
with  a  joint  opposite  the  elbow.  This  was  laid  upon  the  palmar  sur- 
face, and  the  whole  was  nicely  padded,  especially  in  front  of  the  head 
of  the  radius.  In  two  weeks  pasteboard  was  substituted  for  the  an- 
gular splint.  At  the  end  of  six  weeks  I  was  permitted  to  examine 
the  arm  and  found  the  head  of  the  radius  perfectly  in  place,  but  the 
points  of  fracture  slightly  salient.  All  of  the  motions  of  the  arm  were 
fully  restored. 

June  2,  1845.  C.  C,  ast.  9,  fell  upon  his  arm,  breaking  the  ulna 
obliquely  near  its  middle,  and  dislocating  the  head  of  the  radius  for- 
wards. Dr.  J.  P.  White  being  called,  requested  me  to  visit  the  patient 
also  with  him.  We  found  one  of  the  broken  fragments  protruding 
through  the  skin,  on  the  inside  of  the  arm. 

With  great  ease,  and  by  simply  pressing  with  considerable  force 
upon  the  head  of  the  radius,  it  was  made  to  slide  into  its  socket.  The 
case  was  left  in  charge  of  Dr.  White. 

Five  weeks  after,  I  found  all  of  the  motions  of  the  forearm  com- 
pletely restored,  except  that  he  could  not  extend  it  perfectly.  The 
head  of  the  radius  was  also  a  little  more  prominent  in  front  than  in 
the  opposite  arm. 

Four  or  five  years  afterwards,  the  projection  of  the  head  of  the 
radius  had  disappeared,  and  the  functions  of  the  arm  were  perfect. 

The  following  example  of  compound  and  comminuted  fracture  of 
the  ulna  will  illustrate  how  much  may  be  accomplished  by  conserva- 
tive surgery : — 

A  German  lad,  set.  10,  was  run  over  by  a  railroad  car,  Sept.  4, 1857. 
Drs.  C.  F.  Gay  and  Austin  Flint,  Jr.,  were  summoned  immediately; 
but  the  limb  presented  such  a  discouraging  appearance  as  induced 
them  to  send  for  me  also. 

We  found  the  ulna  very  much  broken  near  its  lower  end,  and  about 
two  inches  of  it  entirely  gone.  The  radius  was  sound.  The  skin  and 
muscles  were  extensively  lacerated  and  torn  oft'  in  shreds. 

After  a  careful  examination,  finding  that  the  radial  and  ulnar 
arteries  continued  to  pulsate,  upon  consultation  together,  we  agreed 
to  attempt  to  save  the  limb.  It  was  accordingly  laid  upon  a  board 
covered  with  a  soft  and  nicely  adjusted  cushion;  such  vessels  as  were 
bleeding  were  tied ;  the  skin  was  loosely  stitched  together,  and  the 
whole  covered  with  a  cotton  cloth  smeared  with  simple  cerate.  Cool 
water  dressings  were  directed,  and  the  boy  was  left  in  charge  of  Drs. 
Gay  and  Flint.  The  skin  subsequently  sloughed  extensively,  and 
also  more  or  less  of  the  muscular  tissue ;  but  on  the  1st  of  May,  1858, 


I 


COEOXOID    PROCESS    OF    THE    ULXA.  299 

about  eight  months  from  the  time  of  the  accident,  it  had  nearly  or 
quite  closed  over,  and  although  his  arm  was  very  much  deformed  and 
maimed,  it  was  still  very  useful ;  indeed,  to  one  who  must  earn  his 
living  by  his  hands  alone,  its  value  is  beyond  estimate. 


§  2.  CoRONOiD  Process  of  the  Ulna. 

Dissections  have  established  the  possibility  of  this  fracture  as  a 
simple  accident  in  the  living  subject;  but  I  have  not  myself  seen  any 
example  of  which  I  can  speak  positively.  In  the  two  following  cases, 
the  existence  of  such  a  fracture  was  at  first  suspected,  but  I  have  now 
very  little  doubt  but  that  my  diagnosis  was  incorrect.  I  shall  relate 
them,  however,  as  examples  of  those  accidents  which  are  likely  to  be 
mistaken  for  fracture  of  this  process. 

A  laboring  man  aged  about  twenty-five  years,  had  been  seen  and 
treated  by  another  surgeon,  for  what  was  supposed  to  be  a  simple 
dislocation  of  the  radius  and  ulna  backwards.  The  surgeon  thought 
he  had  reduced  the  dislocation  very  soon  after  the  accident.  On  the 
following  day  he  found  the  dislocation  reproduced,  and  he  requested 
me  to  see  the  patient  with  him.  The  arm  was  then  much  swollen, 
but  the  character  of  the  dislocation  was  apparent.  By  moderate  ex- 
tension, applied  while  the  arm  was  slightly  flexed,  and  continued  for 
a  few  seconds,  reduction  was  again  effected;  the  bones  returning  to 
their  places  with  a  distinct  sensation;  but  on  releasing  the  arm  the  dis- 
location was  immediately  reproduced.  These  attempts  to  reduce  and 
retain  in  place  the  dislocated  bones  were  repeated  several  times  during 

Fig.  90. 


Fracture  of  the  coronoid  process. 

this  day,  and  on  subsequent  days,  but  to  no  purpose,  and  the  patient 
was  dismissed  after  about  two  weeks  with  the  bones  unreduced. 

The  impossibility  of  retaining  the  bones  in  place,  and  the  existence 
of  an  occasional  crepitus  during  the  manipulation,  inclined  me  to  be- 
lieve at  the  time  that  the  dislocation  was  accompanied  with  a  fracture 
of  the  coronoid  process. 

Another  similar  case  has  since  presented  itself  in  a  child  nine  years 
old,  and  in  which  the  subsequent  examinations  not  only  demonstrated 
the  non-existence  of  a  fracture,  but  also  rendered  doubtful  the  justness 
of  the  conclusions  which  I  had  drawn  in  the  case  just  related. 

This  lad  fell,  Xov.  4,  1855,  and  his  parents  immediately  brought 
him  to  me ;  but  as  he  lived  many  miles  from  town,  I  did  not  see  him 
until  eighteen  hours  after  the  injury  was  received.  I  found  the  arm 
much  swollen,  slightly  flexed  and  proned.  Flexion  and  extension  of 
the  arm  were  very  painful;  the  pain  being  referred  chiefly  to  the  front 
of  the  joint,  near  the  situation  of  the  coronoid  process;  and  at  this 
point  also  there  was  a  discoloration  of  the  size  of  a  twenty-five  cent 


300  FRACTUEES    OF    THE    ULNA. 

piece.  Flexing  the  forearm  moderately  upon  the  arm  and  making 
extension,  the  bones  came  readily  into  place,  but  without  sensation  of 
any  kind,  either  a  snap  or  a  crepitus.  That  the  bones  had  now  re- 
sumed their  position,  however,  I  made  certain  by  a  very  careful  exami- 
nation with  the  hand  and  by  measurement;  yet  they  would  not  remain 
in  place  one  moment  when  the  extension  was  discontinued.  The 
reduction  was  made  several  times,  and  constantly  with  the  same  re- 
sult. We  then  applied  a  right-angled  splint  to  the  arm,  having  first 
reduced  the  bones,  and  thus  were  able  to  retain  them  in  position.  I 
believed  that  the  coronoid  process  was  broken,  and  so  informed  the 
surgeon  to  whose  care  the  boy  was  returned. 

Five  months  after,  he  was  brought  again  to  me,  and  I  then  found 
that  the  radius  and  ulna  had  been  kept  in  place;  the  motions  of  the 
joint  were  perfect,  and  if  the  coronoid  process  had  ever  been  broken  it 
was  now  again  in  its  natural  position,  and  with  every  structure  about  it 
in  a  condition  as  complete  as  it  was  before  the  accident.  For  myself, 
I  do  not  believe  that  so  perfect  a  union  of  this  process  can  happen — at 
least  in  a  case  where,  as  must  have  been  the  fact  in  this  example,  the 
separation  and  displacement  of  the  process  are  such  that  it  no  longer 
offers  an  obstacle  to  the  dislocation  of  the  ulna  backwards  and  upwards. 

Malgaigne  thinks  that  the  fracture  is  more  frequent  than  the  small 
number  of  reported  examples  would  lead  us  to  suppose,  especially 
because  he  has  noticed  how  often  the  summit  of  the  process  is  broken 
off',  when  dislocation  of  the  radius  and  ulna  backwards  are  produced 
artificially  on  the  dead  subject.  In  three  or  four  cases,  also,  of  dis- 
locations of  these  bones  backwards  and  inwards,  which  had  come 
under  his  notice,  he  was  unable  to  feel  this  process,  and  he  therefore 
thought  it  probable  that  it  was  broken  off*.  Other  surgeons  have 
thought,  also,  that  it  was  a  not  infrequent  accident;  and  they  have 
constantly  made  use  of  this  supposition  to  explain  those  cases  in 
which,  the  radius  and  ulna  having  been  dislocated  backwards,  would 
not  afterward  remain  in  place  when  well  reduced.  Fergusson  has 
indeed  made  the  extraordinary  statement  in  relation  to  dislocations  of 
the  radius  and  ulna  backwards  generally,  that  in  these  cases  '"the 
coronoid  process  will  probably  be  broken." 

But  in  my  opinion,  these  fractures  are  exceedingly  rare ;  and  I  think 
these  gentleman  need  to  have  furnished  some  more  conclusive  evi- 
dence of  the  correctness  of  their  opinions,  than  can  be  found  in  their 
writings,  or  in  the  writings  of  any  other  surgeons,  which  I  have  seen. 

Malgaigne  mentions  three  reported  examples,  namely  :  one  pub- 
lished by  Combes  Brassard,  an  Italian  surgeon,  in  1811,  which  Bras- 
sard saw  only  after  a  lapse  of  three  months;  one  seen  by  Penneck,  and 
published  in  the  Lancet  in  1828,  the  patient  then  being  sixty  years 
old  and  the  accident  having  occurred  while  he  was  a  young  man  ;  the 
third  was  seen  by  Sir  Astley  Cooper,  several  months  after  the  accident, 
and  is  reported  by  himself  in  his  excellent  treatise  on  Fractures  and 
Dislocations.  Says  Mr.  Cooper:  "It  was  thought,  at  the  consultation 
which  was  held  about  him  in  London,  that  the  coronoid  process  was 
detached  from  the  ulna."  This  was  the  only  living  example  seen  by 
Mr.  Cooper  in  his  long  and  immensely  varied  surgical  practice ;  and 


COEONOID    PROCESS    OF    THE    ULNA.  301 

even  here  we  cannot  fail  to  notice  the  apparent  reserve  with  which  he 
expresses  his  opinion —  "  It  was  thought  at  the  consultation." 

To  these  examples  our  own  researches  have  added  a  few  others. 

Dorsey  says  that  Dr.  Physick  once  saw  a  fracture  of  the  coronoid 
process.  The  symptoms  resembled  a  luxation  of  the  forearm  back- 
wards, "  except  that  when  the  reduction  was  effected,  the  dislocation 
was  repeated,  and  by  careful  examination,  crepitation  was  discovered. 
The  forearm  was  kept  flexed  at  a  right  angle  with  the  humerus.  The 
tendency  of  the  brachieus  internus  to  draw  up  the  superior  fragment, 
was  counteracted  in  some  measure  by  the  pressure  of  the  roller  above 
the  elbow.  A  perfect  cure  was  readily  obtained.'"  In  1880,  Dr.  Wm. 
M.  Fahnestock  reported  a  case  occurring  in  a  boy,  who,  having  fallen 
from  a  haymow,  received  the  whole  weight  of  his  body  "  on  the  back 
part  of  the  palm  of  the  left  hand,"  while  the  arm  was  extended  for- 
wards. It  seemed  to  be  a  dislocation  of  the  forearm  backwards,  but 
when  reduced  it  was  again  immediately  displaced,  with  an  evident 
crepitus.  The  arm  was  secured  in  the  angular  splint  of  Dr.  Physick, 
and  "recovered  very  speedily."^  Dr.  Couper,  of  the  Glasgow  Infirm- 
ary, also  has  reported  a  dislocation  of  the  forearm  backwards  and  out- 
wards occurring  in  a  young  man  aged  seventeen,  and  which  he  thinks 
was  accompanied  with  this  fracture.  The  dislocation  was  easily  re- 
duced, but  returned  again  immediately  on  ceasing  the  extension.  The 
fragment  was  not  felt,  nor  does  he  speak  of  crepitus ;  the  existence  of 
the  fracture  being  inferred  from  the  fact  that  the  bones  would  not 
remain  in  place  without  help.  The  forearm  was  placed  across  the 
chest,  with  the  fingers  pointing  toward  the  opposite  shoulder,  and 
secured  in  this  position  with  splints  and  a  bandage.  At  the  end  of 
four  weeks  union  had  taken  place,  with  only  slight  deformity,  although 
with  some  stiffness  of  the  joint. 

In  relation  to  this  example,  the  editor  remarks  that  the  symptoms 
were  not  to  his  mind  conclusive  in  determining  the  existence  of  a 
fracture  of  the  coronoid  process,  and  he  inclines  to  the  belief  that  it 
was  rather  an  oblique  fracture  of  the  lower  extremity  of  the  humerus. 
"  In  cases  like  these,"  he  adds,  "  where  very  rare  accidents  are  suspected, 
we  think  that  unless  the  diagnosis  is  clear,  the  leaning  should  always 
be  the  other  way :  we  mean,  that,  coeieris  paribus^  the  symptoms  should 
rather  be  referred  to  the  common  than  the  extraordinary  injury.  The 
contrary  practice  introduces  a  dangerous  laxity  in  diagnosis."'^ 

In  the  American  Medical  Monthly  for  October,  1855,  also,  I  find 
the  report  of  a  trial  for  malpractice,  in  which  a  lad  nine  years  old 
received  some  injury  about  the  elbow-joint  which  resulted  in  a  maim- 
ing. The  defendant  claimed  that  there  had  been  a  dislocation  of  the 
forearm  backwards,  accompanied  either  with  a  fracture  of  the  trochlea 
of  the  humerus,  or  of  the  coronoid  process  of  the  ulna. 

Dr.  Crosby,  of  Dartmouth  College,  testified  that  he  had  never  met 
with  a  fracture  of  this  process,  yet  he  would  not  say  that  it  did  not 
exist  in  this  case.     He  was  not  able  to  decide  positively.     Dr.  Peaslee, 

'  Dorsey,  Elements  of  Surgery,  vol.  i.  p.  152.     Philadelphia.  1813. 

^  Fahnestock,  Amer.  Journ.  Med.  Sci.,  vol.  vi.  p.  267. 

^  Couper,  Lond.  Med.-Chir.  Rev.,  new  ser  ,  vol.  xi.  p.  509. 


302  FRACTUEES    OF    THE    ULNA. 

of  the  same  college,  thought  it  altogether  probable  that  it  had  been 
broken,  and  Dr.  Spaulding  was  of  the  opinion  fully  that  it  had  been 
broken. 

The  jury  did  not  agree,  and  a  non-suit  was  finally  allowed  by  the 
court. 

The  defendant,  in  his  report  of  the  trial,  seems  to  me  to  have  justly 
complained  that  Mr.  Fergusson  has  said,  that  in  a  dislocation  of  the 
forearm  backwards  "  the  coronoid  process  will  probably  be  broken." 
This  was  urged  in  the  trial  by  the  plaintiff's  counsel  as  contradicting 
the  medical  testimony,  and  as  evidence  of  a  conspiracy  on  the  part 
of  the  surgeons  to  defeat  the  ends  of  justice;  since  they  constantly 
affirmed  that  the  accident  was  so  rare  as  not  to  have  been  reasonably 
expected,  and  that  a  failure  to  look  for  or  to  discover  it  did  not  imply 
a  lack  of  ordinary  skill  or  care.^ 

Says  Mr.  Liston:  "The  coronoid  process  is  occasionally  pulled  or 
pushed  off  from  the  shaft,  more  especially  in  young  subjects.  I  saw 
a  case  of  it  lately,  in  which  the  injury  arose  in  consequence  of  the 
patient,  a  boy  of  eight  years,  having  hung  for  a  long  time  from  the 
top  of  a  wall  by  one  hand,  afraid  to  drop  down  ;"^  after  whom.  Miller, 
Erichsen,  Skey,  Lonsdale,  and  most  of  the  Scotch  and  English  sur- 
geons have  repeated  the  assertion  that  this  process  may  be  broken  in 
this  manner  by  the  action  of  the  brachialis  anticus  alone,  yet  no  one 
of  them  has  to  this  day  seen  another  example. 

The  explanation  of  the  accident  in  the  case  of  the  boy,  given  by 
Liston,  implies  two  anatomical  errors:  first,  that  the  coronoid  process 
is  an  epiphysis  during  childhood;  and  second,  that  the  brachialis 
anticus  is  inserted  upon  its  summit.  The  coronoid  process  is  never 
an  epiphysis,  but  is  formed  from  a  common  point  of  ossification  with 
the  shaft ;  the  olecranon  process  and  the  lower  extremity  of  the  ulna 
having  also  separate  points  of  ossification.  Moreover,  the  brachialis 
anticus  has  its  insertion  at  the  base  of  the  process  and  partly  upon 
the  body  of  the  ulna,  but  in  no  part  upon  its  summit;  indeed,  the 
process  seems  rather  to  be  intended  as  a  pulley  over  which  the  bra- 
chialis anticus  may  play ;  resembling  also,  somewhat,  in  its  function, 
the  patella;  serving  to  protect  the  joint  and  perhaps  the  muscle  itself 
from  becoming  compressed  in  the  motions  of  the  joint.  Certainly  it 
could  never  have  been  broken  by  the  action  of  this  muscle,  and  the 
case  mentioned  by  Mr.  Liston  must  find  some  other  explanation.  It 
may  have  been  a  rupture  of  the  brachialis  anticus  itself,  or  of  the 
biceps,  or  possibly  a  forward  luxation  of  the  head  of  the  radius. 
Either  of  these  suppositions  is  more  rational  than  the  statement  made 
by  Mr.  Liston,  because  either  one  of  them  is  possible,  while  his  suppo- 
sition is  impossible. 

These,  if  I  except  my  own,  constitute  all  of  the  supposed  examples 
seen  in  the  living  subject,  of  which  I  find  any  record ;  eight  in  all. 

The  first  two  were  not  entirely  satisfactory  to  Malgaigne ;  the  third 
is  spoken  of  cautiously  by  Sir  Astley  Cooper,  as  if  it  needed,  in  addi- 
tion to  his  own  great  name,  the  indorsement  of  the  "London  council." 

1  Op.  cit.,  vol.  iv.  p.  339.  ^  Liston,  Practical  Surgery,  p.  55. 


COROXOID    PROCESS    OF    THE    ULXA.  803 

Dorsey  reports  his  case  upon  hearsay,  and  the  result  is  quite  too  satis- 
factory to  give  it  much  claim  to  credibility.  Fahnestock's  case  is  to 
our  mind  far  from  being  fully  proven.  Couper's  case  is  doubted  by 
Dr.  Johnson ;  and  the  ISTew  Hampshire  case  was  not  made  out  satis- 
factorily to  either  the  jury  or  the  medical  men.  Liston's  case  was 
simply  impossible. 

Certainly  it  is  not  upon  such  testimony  as  this  that  we  can  rely  to 
sustain  Mr.  Fergusson's  opinion  that  it  is  likely  to  occur  in  all  dis- 
locations of  the  forearm  backwards,  or  of  Malgaigne's  conjecture  that 
it  is  of  more  frequent  occurrence  than  the  published  cases  would  seem 
to  show.  Nor  will  it  be  regarded  as  conclusive,  that  the  beak  of  the 
process  is  often  found  broken  after  luxations  made  upon  the  subject; 
since  between  luxations  thus  produced  and  luxations  occurring  in  the 
living  subject  there  exists  this  important  difl'erence :  that  in  the  case 
of  the  latter,  muscular  action  is  the  principal  agent  in  the  production 
of  the  dislocation,  while  in  the  former  it  is  the  external  force  alone 
which  drives  the  bone  from  its  socket. 

The  fact,  therefore,  that  so  few  cases  have  ever  been  reported,  and 
that  most  of  these  are  far  from  having  been  clearly  made  out,  remains 
presumptive  evidence  that  the  actual  cases  are  exceedingly  rare ;  but 
if  to  this  we  add  such  negative  evidence  as  is  furnished  by  actual  dis- 
sections, and  by  examinations  of  the  pathological  cabinets  of  the  world, 
we  think  the  testimony  is  almost  conclusive. 

Only  four  specimens  have  been  mentioned  by  any  of  the  surgical 
writers  known  to  me.  Sir  Astley  Cooper  says  that  a  person  was 
brought  to  the  dissecting  room  at  St.  Thomas's  Hospital,  who  had  been 
the  subject  of  this  accident.  "  The  coronoid  process,  which  had  been 
broken  off  within  the  joint,  had  united  by  a  ligament  only,  so  as  to 
move  readily  upon  the  ulna,  and  thus  alter  the  sigmoid  cavity  of  the 
ulna  so  much  as  to  allow  in  extension  that  bone  to  glide  backwards 
upon  the  condyles  of  the  humerus."^  Mr.  Bransby  Cooper  adds  in  a 
note  that  the  external  condyle  of  the  humerus  was  also  broken  and 
united  by  ligament. 

Samuel  Cooper  describes,  rather  obscurely,  a  specimen  contained  in 
the  University  College  Museum,  "in  which  the  ulna  is  broken  at  the 
elbow,  the  posterior  fragment  being  displaced  backwards  by  the  action 
of  the  triceps;  the  coronoid  process  is  broken  off;  the  upper  head  of 
the  radius  is  also  dislocated  from  the  lesser  sigmoid  cavity  of  the  ulna, 
and  drawn  upwards  by  the  action  of  the  biceps.  In  this  complicated 
accident,  the  ulna  is  broken  in  two  places." 

Malgaigne  says  that  Telpeau  has  also  established  by  an  autopsy  the 
existence  of  a  fracture  of  the  coronoid  apophysis,  but  without  having 
given  any  further  particulars  in  relation  to  the  case. 

In  addition  to  these  examples,  Charles  Gibson,  of  Eichmond,  Ya., 
has  stated  to  me  by  letter  that  he  has  in  his  possession  a  specimen  of 
this  fracture,  evidently  belonging  to  an  adult.  The  process  was 
broken  transversely  near  its  extremity,  and  has  united  again  quite 
closely  and  without  any  displacement,  and  without  ensheathing  callus, 

'  A.  Cooper,  Dislocations  and  Fractures,  p.  411. 


304  FEACTURES    OF    THE    ULNA. 

We  must  subject  these  specimens  to  analysis  also.  The  first  two 
were  complicated  with  other  fractures,  and  the  second,  especially, 
seems  to  have  been  a  general  crushing  of  all  the  bones  concerned  in 
the  formation  of  the  elbow-joint:  neither  of  them  could  have  been 
occasioned  by  contractions  of  the  brachialis  anticus,  while  only  that 
one  described  by  Sir  Astley  Cooper  could  have  been  the  result  of  a 
dislocation  of  the  forearm  backwards.  Of  the  specimen  said  to  have 
been  seen  by  Velpeau,  I  am  unable  to  speak  without  more  circum- 
stantial knowledge  of  its  condition.  Nor  can  I  speak  very  confidently 
of  that  belonging  to  my  distinguished  friend.  Dr.  Gibson,  of  Virginia. 
Notwithstanding  the  respect  which  I  entertain  for  his  opinion,  I  can- 
not avoid  a  suspicion  that  the  bone  was  never  broken  at  all,  since  I 
find  it  more  easy  to  believe  that  he  is  deceived  by  certain  appearances, 
than  that  it  should  have  united  by  bone  again,  and  so  perfectly  as  not 
to  leave  any  line  of  separation  or  degree  of  displacement.  Certainly 
the  fracture  was  too  high  to  have  been  produced  by  the  action  of  the 
muscle,  if  such  a  thing  were  ever  possible ;  and  if  broken  by  a  dislo- 
cation, which  must  have  forced  it  violently  from  its  position,  as  the 
ulna  was  driven  upwards,  it  is  to  me  incredible  that  it  should  ever  be 
made  to  unite  again  so  perfectly. 

We  are  therefore  left  as  before  with  no  evidence  that  the  coronoid 
process  was  ever  broken  by  the  action  of  a  muscle,  and  with  only  one 
example  in  which  it  is  probable  that  a  fracture  occurred  as  a  conse- 
quence of  a  dislocation  of  the  radius  and  ulna  backwards.  If  then  it 
does  happen  that  in  this  dislocation  it  is  pretty  often  found  difficult  or 
impossible  to  retain  the  bones  in  place  without  aid,  it  will  be  the  part 
of  prudence  to  ascribe  this  troublesome  circumstance  to  some  more 
common  accident  than  a  fracture  of  the  coronoid  process:  perhaps  to 
a  fracture  of  some  portion  of  the  lower  end  of  the  humerus,  or  to  a 
disruption,  more  or  less  complete,  of  the  tendons  of  the  biceps  and 
brachialis  anticus,  together  with  the  ligaments  which  surround  the 
joint. 

Causes. — It  is  probable  that  this  process  will  be  sometimes  broken 
in  a  fall  upon  the  palm  of  the  hand ;  the  force  of  the  blow  being 
received  directly  upon  the  lower  end  of  the  radius,  and  through  its 
numerous  muscles  and  ligamentous  attachments  being  indirectly  con- 
veyed to  the  ulna,  producing  a  violent  concussion  of  the  coronoid 
process  against  the  trochlea  of  the  humerus,  and  resulting  finally  in 
a  fracture  of  this  process  and  a  dislocation  of  both  bones  of  the  fore- 
arm backwards.  The  gentleman  seen  by  Sir  Astley  had  fallen  upon 
his  extended  hand  while  in  the  act  of  running.  Brassard's  patient 
had  fallen  also  upon  his  hand  with  his  arm  extended  in  front.  Pen- 
neck's  patient,  an  old  man  of  sixty  years,  had  fallen  upon  the  palm 
of  his  hand,  and  Fahnestock's  fell  upon  the  "  back  of  the  palm."  In 
no  other  case  is  the  point  upon  which  the  blow  was  received  particu- 
larly mentioned.  In  two  of  the  examples  mentioned  by  Malgaigne 
there  was  a  luxation  of  the  forearm  backwards ;  such  was  also  the 
fact  in  the  case  seen  by  Fahnestock ;  in  Couper's  case  it  was  dislocated 
backwards  and  outwards,  and  in  Sir  Astley's  case  I  infer  that  there 
was  only  a  subluxation  of  the  ulna  backwards. 


COROXOID    PROCESS    OF    THE    ULNA.  305 

"We  know  of  no  other  causes,  therefore,  than  such  as  equally  tend 
to  produce  dislocations  at  the  elbow-joint,  unless  we  except  direct 
crushing  blows,  which  of  course  may  break  the  bones  at  any  point 
upon  which  the  force  happens  to  be  applied. 

Sym'pioms. — Partial  or  complete  displacement  of  the  ulna,  or  of  the 
radius  and  ulna  backwards,  accompanied  with  the  usual  signs  of  these 
luxations ;  to  which  may  be  possibly  added  crepitus ;  and  it  is  fair  to 
presume  that  in  some  examples  the  fragment  carried  forwards  by  being 
driven  against  the  trochlea,  may  be  felt  displaced  and  movable  in  the 
bend  of  the  elbow.  Brassard  affirms  that  it  was  so  with  the  patient 
whom  he  saw.  If  only  the  summit  is  broken  off,  the  brachialis  anticus 
could  have  no  influence  upon  it,  but  if  it  were  broken  fairly  through 
the  base,  it  might  be  displaced  slightly  in  the  direction  of  the  action 
of  this  muscle. 

The  symptoms,  however,  which  have  been  regarded  as  most  diag- 
nostic are  the  disposition  to  re-luxation  manifested  in  most  of  these 
examples  when  the  extension  has  been  discontinued  ;  and  especially 
the  fact  that  the  olecranon  was  particularly  prominent  when  the  arm 
was  extended,  but  that  it  resumed  its  natural  position  when  the  arm 
was  flexed  to  a  right  angle.  But  I  am  unable  to  understand  how 
either  of  these  circumstances  can  be  better  explained  upon  the  suppo- 
sition of  a  fracture  of  this  apophysis,  than  without  such  a  supposition. 
If  the  reduction  of  both  bones  is  once  effected,  even  though  the  sup- 
port of  the  coronoid  process  is  completely  lost,  the  head  of  the  radius 
ought  to  prevent  a  re-luxation  unless  the  arm  is  disturbed  again;  nor 
can  I  understand  why,  when  the  elbow  is  bent,  the  re-luxation  is  less 
likely  to  occur;  since,  although  in  this  position  the  humerus  bears 
less  directly  upon  the  process,  the  difference  in  this  respect  must  be 
very  little,  for  in  whatever  position  the  arm  is  placed,  so  long  as  the 
radius  retains  its  position  the  ulna  cannot  be  drawn  very  forcibly 
against  the  humerus;  while,  on  the  other  hand,  by  flexing  the  arm 
the  power  of  the  biceps,  and  of  such  fibres  of  the  brachialis  as  remain 
attached  to  the  ulna,  to  aid  in  the  maintenance  of  reduction  is  com- 
pletely lost;  and  at  the  same  moment  the  resistance,  and  consequent 
power  of  the  triceps  to  produce  the  luxation,  are  greatly  increased. 

In  short,  we  must  confess  that  we  are  here,  also,  notwithstanding 
the  confidence  with  which  writers  have  spoken  of  the  signs  of  this 
accident,  very  much  in  doubt;  nor  do  we  see  how  these  doubts  can 
be  removed  until  we  have  in  detail  the  symptoms  of  at  least  one 
example,  the  indubitable  existence  of  which  has  been  subsequently 
verified  by  dissection. 

Prognosis. — In  the  case  of  Cooper's  patient,  seen  several  months 
after  the  accident,  the  ulna  projected  backwards  while  the  arm  was 
extended,  but  it  was  without  much  difficult}'-  drawn  forwards  and  bent, 
and  then  the  deformity  disappeared.  He  thought  that  during  exten- 
sion the  ulna  slipped  back  behind  the  inner  condyle  of  the  humerus. 
Brassard's  patient,  seen  after  three  months,  retained  the  power  of  pro- 
nation and  supination,  with  also  extension,  but  flexion  was  completely 
impossible,  the  forearm  being  arrested  in  this  direction  by  the  small, 
slightly  movable  fragment  of  bone  in  front  of  the  elbow-joint,  and 
20 


806  FEACTUEES    OF    THE    ULNA. 

which  was  supposed  to  be  the  process  itself.  Penneck's  old  man,  who 
had  met  with  the  accident  in  boyhood,  had  still  the  radius  luxated 
forwards  and  outwards,  and  the  olecranon  more  salient  backwards  than 
in  the  sound  arm.  Extension  and  flexion  were  nearly  but  not  quite 
complete.  Fahnestock  informs  us  that  his  patient  "recovered  com- 
pletely," but  whether  without  deformity  or  maiming  we  are  not  told. 
Couper  says  the  bone  was  united  in  four  weeks,  and  that  only  a  slight 
deformity  and  a  little  stiffness  remained.  Physick's  patient  made  a 
perfect  recovery. 

Let  us  come  again  to  the  dissections.  Eejecting  the  doubtful 
specimen  belonging  to  Dr.  Gibson,  we  have  an  exact  account  of  only 
two,  and,  indeed.  Sir  Astley  Cooper  alone  has  described  the  mode  of 
union.  Samuel  Cooper  says  that  in  the  case  of  the  University  College 
specimen  the  radius  is  dislocated  forwards  and  upwards,  and  the  ole- 
cranon is  displaced  backwards,  but  he  does  not  say  whether  the 
coronoid  process  has  united,  nor  describe  its  position ;  but  Sir  Astley 
informs  us  that  in  the  example  seen  and  dissected  by  him  the  process 
v/as  united  by  ligament,  which  was  sufficiently  long  and  flexible  to 
allow  the  fragment  to  move  upwards  and  downwards  in  the  motions 
of  flexion  and  extension. 

In  the  absence  of  any  other  testimony,  we  may  be  allowed  to  ex- 
press an  opinion  that  when  the  fracture  has  taken  place  across  the 
summit  or  above  the  insertion  of  the  brachialis  anticus,  nothing  but  a 
ligamentous  union  can  be  regarded  as  possible,  since  the  fragment 
can  only  derive  nourishment  from  a  few  untorn  fibres  of  the  capsule 
and  perhaps  of  the  internal  lateral  ligaments;  and  although,  it  may 
not  be  displaced,  it  cannot  have  the  advantage  of  impaction,  upon 
which  alone,  I  suspect,  a  fracture  of  the  neck  of  the  femur  within  the 
capsule  must  rely  for  a  bony  union,  if  it  ever  does  so  unite.  If,  how- 
ever, the  fracture  has  taken  place  at  the  base,  and  fortunately  it  has 
not  become  much  displaced  by  the  force  of  the  concussion  against  the 
humerus,  it  does  not  seem  to  me  so  impossible  that  under  favorable 
circumstances  a  bony  union  might  now  and  then  occur.  It  will  be 
remembered  that  a  good  portion  of  the  attachment  of  the  brachialis 
anticus  is  still  below  the  fracture,  and  the  remaining  fibres  are  not 
therefore  very  likely  to  displace  the  fragment,  especially  when  the 
arm  is  sufficiently  flexed,  so  as  to  properly  relax  this  muscle. 

It  will  be  of  small  importance,  however,  whether  the  union  is  bony 
or  ligamentous,  provided  only  there  is  not  great  displacement. 

Treatment. — Whatever  view  we  take  of  the  pathology  of  this  acci- 
dent, the  rational  mode  of  treatment  would  seem  to  consist  in  flexing 
the  arm  at  a  right  angle,  and  retaining  it  a  sufficient  length  of  time  in 
that  position ;  not  forgetting,  however,  the  danger  of  anchylosis  from 
long-continued  confinement  in  one  position. 

An  angular  splint  may  be  useful  in  preventing  motion  at  first,  but 
I  think  it  ought  not  to  be  continued  beyond  seven  or  ten  days  at  the 
most.  After  this,  a  simple  sling  is  all  that  can  be  necessary,  since 
from  this  period  some  motion  must  be  given  to  the  joint  if  we  would 
take  the  proper  precautions  to  prevent  stiffness.  Sir  Astley  Cooper 
thought  the  limb  ought  to  be  kept  immovable  three  weeks,  and  Vel- 


CORONOID    PROCESS    OF    THE    ULNA.  307 

peau  preferred  four ;  but  I  cannot  agree  with  them,  believing  that  the 
question  of  the  future  mobihtj  of  the  elbow-joint  is  vastly  niore  im- 
portant than  the  question  of  a  bony  or  ligamentous  union  between 
the  fragments.  Couper  says  that  he  adopted  in  the  treatment  of  the 
case  reported  by  him,  extreme  flexion,  but  both  Physick  and  Fahnes- 
tock  placed  the  arm  at  right  angles,  and  Sir  Astley  Cooper  has  re- 
commended the  same  position.  The  latter  position  has  always  the 
advantage  in  case  permanent  anchylosis  occurs,  and  the  former  cannot 
add  much  to  the  chance  of  complete  replacement  of  the  fragment. 

Bandages  are  only  serviceable  to  retain  the  splint  in  place,  and  they 
may  be  thrown  aside  as  soon  as  the  splint  is  removed. 

While  these  pages  are  going  to  press,  I  have  met  with  the  following 
two  additional  reported  examples  of  fracture  of  the  eoronoid  process: — 

Thomas  Jenkins,  admitted  to  the  New  York  City  Hospital,  Feb. 
5,  1850,  having  fallen,  a  few  hours  before  admission,  from  the  roof  of 
a  building  to  the  ground,  a  height  of  thirty  feet.  Both  bones  of  the 
right  forearm  were  dislocated  backwards  at  the  elbow ;  the  right  radius 
had  also  sustained  a  comminuted  fracture  of  its  head  and  of  its  lower 
extremit}'-,  the  head  being  completely  detached  from  the  articular  sur- 
face of  the  OS  brachii.  Besides  this  injury,  there  was  a  fracture  of  the 
eoronoid  process  of  the  right  ulna,  a  comminuted  fracture  of  the  left 
radius,  fracture  of  the  left  ulna,  compound  fracture  of  the  right  patella, 
and  compound  fracture  of  the  skull  at  its  base  and  above  it,  with  lacera- 
tion of  the  dura  mater  and  brain;  under  which  injuries  the  patient 
soon  expired.^ 

Terrance  O'Brian,  set.  16,  was  admitted  to  the  Brooklyn  Hospital, 
Aug,  13, 1856.  In  attempting  to  pass  his  hand  over  a  pulley  connected 
with  some  machinery,  his  arm  was  caught,  and  he  was  drawn  over  the 
shaft,  producing  a  compound  dislocation  at  the  elbow  joint,  a  fracture 
of  the  inner  condyle  of  the  humerus,  and  a  fracture  of  the  eoronoid 
process  of  the  ulna.  The  lower  end  of  the  humerus  protruded  through 
the  skin  in  front  of  the  joint,  two  inches.  The  dislocation  was  reduced, 
the  arm  placed  upon  an  angular  splint,  and  cold  water  dressings 
applied.  At  the  end  of  about  seven  weeks,  the  wounds  were  granulat- 
ing nicely,  and  the  surgeon  felt  assured  that  the  limb  would  be  saved, 
and  he  hoped  also  that  some  motion  in  the  joint  would  be  obtained.^ 

The  first  of  these  examples  does  not  appear  to  have  been  proven  by 
a  dissection,  although  the  man  died. 

The  second  example  lacks  also  this  same  important  testimony;  and 
indeed  the  report  is  too  brief  and  loose  to  inspire  full  confidence  in  its 
accuracy.  In  neither  case  does  the  surgeon  seem  to  have  regarded 
the  fracture  of  this  process  as  an  unusual  circumstance,  or  as  an  acci- 
dent of  difficult  diagnosis,  and  to  substantiate  which  he  would  be  ex- 
pected to  say  more  than  simply  that  it  had  occurred.  It  must  be 
noticed  also,  that  if  we  admit  these  two  as  well-proven  examples  of 
this  fracture,  they  are  neither  of  them  examples  of  simple,  uncompli- 
cated fractures. 

'  Lente's  Hospital  Reports.     N.  Y.  Journ.  Med.,  &c.,  N.  S.,  vol.  v.  p.  25,  July,  1850. 
^  Enos's  Brooklyn  Hospital  Reports.  N.  Y.  Journ,  Med.,  &c.,  Third  Ser,,  vol.  ii,  p. 
98,  Jan.  1857. 


808  FEACTUEES    OF    THE    ULNA. 


§  3.  Fractures  op  the  Olecranon  Process. 

Causes. — So  far  as  I  have  been  able  to  ascertain,  all  of  the  fractures 
of  this  process  which  I  have  seen  were  occasioned  by  falls  upon  the 
elbow,  or  by  blows  inflicted  directly  upon  the  part.  Malgaigne  has, 
however,  been  able  to  collect  accounts  of  six  examples  of  fracture  of  the 
olecranon,  produced,  as  is  affirmed,  by  the  violent  action  of  the  triceps ; 
as  in  pushing  with  the  arm  slightly  flexed,  in  throwing  a  ball,  in 
plunging  into  the  water  wnth  the  arms  extended,  etc.;  but  only  four 
of  these  reported  examples  does  he  think  are  sufficiently  authenticated 
to  entitle  them  to  be  received  as  facts ;  nor  do  I  think  it  possible  to 
affirm  positively  that  in  any  instance,  where  the  whole  process  is  broken 
off,  the  triceps  alone  has  occasioned  the  separation.  For  example, 
Capiomont  reports  the  case  of  a  cavalier,  who,  being  intoxicated,  was 
thrown  head  foremost  from  his  horse,  and  striking  probably  upon  his 
hand,  was  found  to  have  broken  the  olecranon  process.  We  do  not, 
in  this  example,  see  evidence  alone  of  a  forcible  contraction  of  the 
triceps,  but  also  of  violent  pressure  against  the  hand  and  in  the  di- 
rection of  the  axis  of  the  forearm  toward  the  elbow-joint,  by  which 
the  olecranon  process  might  have  been  so  thrown  forwards  against  the 
fossa  of  the  humerus  as  to  cause  its  separation.  The  same  explanation 
might  apply  to  several  of  the  other  examples. 

Point  and  Direction  of  Fracture;  Displacement^  etc, — The  process  may 
be  broken  at  its  summit,  at  its  base,  or  intermediate  between  these  two 
extremes,  the  last  of  which  is  the  most  common. 

It  is  probable  that  when  the  action  of  the  triceps  alone  has  pro- 
duced the  fracture,  it  will  be  found  that  only  the  summit,  or  that 
portion  which  receives  the  insertion  of  the  triceps,  has  been  broken 
off.  Malgaigne,  who  had  been  able  to  find  upon  record  only  two  cases 
of  a  fracture  of  the  extreme  end  of  the  process,  declares  that  they 
were  both  occasioned  by  muscular  action. 

Fractures  of  the  middle  are  generally  transverse,  or  only  slightly 
oblique,  occurring  in  the  line  of  the  junction  of  the  epiphysis  with 
the  diaphysis.  We  think,  also,  we  have  reasons  for  believing  that 
these  only  occur  as  a  consequence  of  a  fall  upon  the  elbow,  or  of  a 
blow  upon  the  extreme  point  of  the  elbow,  when  the  forearm  is  con- 
siderably flexed  upon  the  arm ;  the  direction  of  the  obliquity,  when 

any  is  found  to  exist,  being  gene- 
Fig-  9l.  rally  from    above  downwards   and 
from   behind    forwards,    indicating 
X\a\                                               that  the  direction  of  the  force  was 

also  from  behind. 

Fractures  through  the  base  are 
generally  quite  oblique,  the  line  of 
fracture  extending  from  before 
downwards  and  backwards,  so  that 
not  only  the  whole  of  the  process, 

but  a  portion  of  the  back  of  the 

Fracture  at  the  base.  shaft,    is   Carried   away  ;    and   this 


FRACTURES    OF    THE    OLECRANON    PROCESS.  309 

accident  can  scarcely  happen,  except  bj  a  blow  received  upon  the 
lower  end  of  the  humerus,  directly  in  front  of  the  process;  or,  what 
would  amount  to  the  same  thing,  by  a  blow  from  behind,  received 
upon  the  ulna  just  below  the  olecranon  process,  or  by  wrenching  the 
forearm  violently  back,  while  the  humerus  is  fixed. 

The  only  displacement  to  which  the  upper  fragment  seenns  to  be 
liable,  is  in  the  direction  of  the  triceps;  and  the  degree  of  this  dis- 
placement does  not  depend  so  much  upon  the  point  at  which  the 
fracture  has  taken  place  as  upon  the  violence  which  has  occasioned  it, 
the  extent  of  the  disruption  of  the  ligaments,  aponeurosis  of  the  triceps 
and  of  the  capsule,  and  upon  whether,  since  the  accident,  the  arm  has 
been  flexed  or  kept  extended. 

In  two  instances,  I  have  found  distinct  crepitus  immediately  after 
the  fracture  had  occurred,  produced  by  only  moving  the  fragment 
laterally,  showing  plainly  that  little  or  no  displacement  had  taken 
place.  The  following  example  will  show  also  that  this  displacement 
does  not  always  happen  even  after  the  lapse  of  several  days,  and  where 
no  surgical  treatment  has  been  adopted. 

Samuel  Duckett,  tet.  14,  fell  upon  the  point  of  the  elbow,  and  two 
days  after  was  admitted  to  the  Buffalo  Hospital  of  the  Sisters  of  Charity. 
The  elbow  was  then  much  swollen,  but  no  crepitus  could  be  detected, 
and  he  could  nearly  straighten  his  arm  by  the  action  of  the  triceps. 
On  the  sixth  day,  the  swelling  having  sufficiently  subsided,  a  distinct 
crepitus  was  discovered  when  the  olecranon  process  was  seized  between 
the  fingers,  and  moved  laterally.  We  extended  the  arm  immediately, 
and  applied  a  long  gutta-percha  splint  to  the  whole  front  of  the  arm 
and  forearm,  securing  it  in  place  with  a  roller.  On  the  eleventh  day, 
five  days  after  the  first  dressing,  the  splint  was  taken  off,  and  its  angle 
at  the  elbow-joint  slightly  changed;  and  this  was  repeated  every  day 
until  the  twenty-second  from  the  time  of  the  accident.  The  splint 
was  then  finally  removed,  when  the  fragment  was  found  to  be  united 
without  any  perceptible  displacement,  and  the  motions  of  the  joint 
were  unimpaired. 

It  must  not  be  inferred,  however,  that  it  is  always  prudent  to  leave 
this  fracture  thus  unsupported,  since  it  has  occasionally  happened 
that  the  displacement,  which  did  not  exist  at  first,  has  taken  place  to 
the  extent  of  half  an  inch  or  more,  after  the  lapse  of  several  days. 
Mr.  Earle  mentions  a  case  in  which  the  separation  did  not  take  place 
until  the  sixth  day,  when  it  was  occasioned  by  the  patient's  attempting 
to  tie  his  neck-cloth. 

Symptoms. — The  usual  signs  of  a  fracture  of  the  olecranon  process, 
are,  when  the  fragments  are  not  separated,  crepitus  discovered  espe- 
cially by  seizing  the  process,  and  moving  it  laterally ;  or,  when  dis- 
placement has  actually  taken  place  the  crepitus  may  be  discovered 
sometimes  by  extending  the  forearm,  and  pressing  the  fragment  down- 
wards until  it  is  made  to  touch  the  lower  fragment;  the  existence  of 
a  palpable  depression  between  the  fragments,  partial  flexion  of  the 
forearm,  and  total  inability,  on  the  part  of  the  patient,  to  straighten 
it  completely,  or  even  to  flex  the  arm  in  some  cases.     If  the  fragments 


310 


FEACTUEES    OF    THE    ULNA. 


do  not  separate,  gentle  flexion  and  extension  of  the  arm,  while  the 
finger  rests  upon  the  process,  may  enable  us  to  detect  the  fracture. 

It  will  sometimes  happen  that,  owing  to  the  rapid  occurrence  of 
tumefaction,  the  evidences  of  a  fracture  will  be  quite  equivocal ;  but, 
in  all  cases  where  a  severe  injury  has  been  inflicted  upon  the  point  of 
the  elbow,  it  will  be  well  to  suspend  judgment  until,  by  repeated  ex- 
aminations, made  on  successive  days,  the  question  is  determined. 
Meanwhile,  the  arm  ought  to  be  kept  constantly  in  an  extended  posi- 
tion, as  if  a  fracture  was  known  to  exist. 

Prognosis. — In  a  large  majority  of  cases,  this  process  becomes  re- 
united to  the  shaft  by  ligament,  which  may  vary  in  length  from  a 
line  to  an  inch  or  more,  and  which  is  more  or  less  perfect  in  different 
cases.  Sometimes  it  is  composed  of  two  separate  bands,  with  an 
intermediate  space,  or  the  ligament  may  have  several  holes  in  it;  at 
other  times  it  is  composed  in  part  of  bone  and  in  part  of  fibrous  tissue; 
but  most  frequently  it  is  a  single,  firm,  fibrous  cord,  whose  breadth 
and  thickness  are  less  than  that  of  the  process  to  which  it  is  attached. 
If  the  fragments  are  maintained  in  perfect  apposition,  a  bony  union 
is  likely  to  occur,  yet  it  is  not  invariably  found  to  have  taken  place, 
even  under  these  circumstances,  Malgaigne  thinks, 
also,  he  has  seen  one  case  in  which  there  was  neither 
bone  nor  fibrous  tissue  deposited  between  the  frag- 
ments. This  was  an  ancient  fracture  at  the  base  of 
the  olecranon ;  the  superior  fragment  remained  im- 
movable during  the  flexion  and  extension  of  the  arm, 
yet  it  could  be  moved  easily  from  side  to  side. 

In  my  own  cases,  I  have  three  times  found  the  frag- 
ments united  without  any  appreciable  separation,  and 
have  presumed  that  the  union  was  bony.  One  of  these 
examples  I  have  already  mentioned;  the  second,  was 
in  the  person  of  a  lady  aged  about  forty  years,  who, 
having  fallen  down  a  flight  of  steps  on  the  8th  of  Sep- 
tember, 1857,  sent  for  me  immediately.  I  found  a 
large  bloody  tumor  covering  the  elbow-joint,  but  there 
was  no  difficulty  in  detecting  a  fracture  of  the  olecra- 
non process.  It  was  easily  moved  from  side  to  side, 
and  this  motion  was  accompanied  with  a  distinct  cre- 
pitus. During  the  first  week,  the  arm  was  only  laid 
upon  a  pillow,  but  as  it  was  found  to  become  gradually 
more  flexed,  and  the  swelling  having  in  a  great  measure  subsided, 
the  arm  was  nearly,  but  not  quite,  straightened,  and  a  long  gutta- 
percha splint  applied  to  the  palmar  surface  of  the  forearm  and  arm. 
The  fragments  united  in  about  twenty  or  twenty-five  days,  and  with- 
out separation,  so  far  as  could  be  discovered  in  a  very  careful  exami- 
nation. 

The  third  example  to  which  I  have  referred,  occurred  in  a  boy 
fourteen  years  old,  and  was  treated  by  Dr.  Benjamin  Smith,  of  Berk- 
shire, Massachusetts.  Sixty-nine  years  after,  he  being  then  eighty- 
three  years  old,  I  found  the  olecranon  process  united  apparently  by 


TJaion  by  ligament. 


I 


FRACTURES  OF  THE  OLECRANON  PROCESS.       311 

bone,  but  to  that  day  be  bad  been  unable  to  straigbten  tbe  arm  com- 
pletely, or  to  supine  it  freely. 

In  one  instance  I  bave  found  tbe  bone,  after  tbe  lapse  of  one  year, 
united  by  a  ligament,  wbicb  seemed  to  be  about  one-quarter  of  an 
incb  in  lengtb,  and  tbe  arm  appeared  to  be  in  all  respects  as  perfect 
as  tbe  otber.     He  could  flex  and  extend  it  freely. 

In  tbe  two  following  examples,  also,  tbe  bond  of  union  was  liga- 
mentous : — 

Jobn  Carbony,  set.  18,  baving  broken  tbe  olecranon,  it  was  treated 
witb  a  straigbt  splint.  Nine  years  after,  I  found  tbe  process  united 
by  a  ligament  balf  an  incb  in  length,  and  he  could  nearly,  but  not 
entirely,  straighten  tbe  arm.  In  all  other  respects  the  functions  and 
motions  of  tbe  arm  were  perfect. 

A  lad,  set.  15,  was  brought  to  me  by  Dr.  Lauderdale,  a  very 
excellent  surgeon  in  tbe  town  of  Geneseo,  Livingston  Co.,  N.  Y., 
whose  olecranon  process  bad  been  broken  by  a  fall  six  months  before, 
and  at  tbe  same  time  tbe  head  of  the  radius  had  been  dislocated  for- 
wards, I  found  tbe  radius  in  place,  and  the  olecranon  process  united 
by  a  ligament  about  balf  an  incb  in  length.  He  was  not  able  to 
straighten  tbe  arm  completely,  tbe  forearm  remaining  at  an  angle  of 
45°  witb  the  arm. 

Treatment. — It  will  surprise  tbe  student  who  is  yet  unacquainted 
with  the  literature  of  our  science,  to  learn  that  in  relation  to  tbe 
treatment  of  a  fracture  of  the  olecranon  process,  a  wide  difference  of 
opinion  has  been  entertained  as  to  what  ought  to  be  tbe  position  of 
the  arm  and  the  forearm,  in  order  to  the  accomplishment  of  the  most 
favorable  results ;  and  that,  while  some  insist  upon  tbe  straight  posi- 
tion as  essential  to  success,  others  prefer  a  slightly  flexed  position, 
and  still  others  bave  advocated  the  right-angled  position.  Thus, 
Hippocrates,  and  nearly  all  of  the  earlier  surgeons,  down  to  a  period 
so  late  as  the  latter  part  of  the  last  century,  directed  that  tbe  arm 
should  be  placed  in  a  position  of  demi-flexion ;  Boyer,  Desault, 
and,  after  them,  most  of  the  French  surgeons  of  our  own  day,  prefer 
a  position  in  which  the  forearm  is  very  slightly  bent  upon  the  arm  ; 
while  Sir  Astley  Cooper,  and  a  large  majority  of  the  English  and 
American  surgeons,  employ  complete  or  extreme  extension. 

The  arguments  presented  by  the  advocates  and  antagonists  of  these 
various  plans  deserve  a  moment's  consideration. 

In  favor  of  the  position  of  demi-flexion,  requiring  no  splints,  and, 
in  tbe  opinion  of  some  writers,  not  even  a  bandage,  but  only  a  sling 
to  support  the  forearm,  it  is  claimed  that  it  leaves  tbe  patient  at 
liberty  at  once  to  walk  about  and  to  move  the  elbow-joint  freely,  so 
soon  at  least  as  tbe  subsidence  of  the  swelling  and  pain  will  permit, 
and  that  in  this  way  the  danger  of  anchylosis  is  greatly  diminished; 
that,  moreover,  if  anchylosis  should  unfortunately  occur,  tbe  limb  is 
in  a  much  better  position  for  the  proper  performance  of  its  most  or- 
dinary functions  than  if  it  were  extended.  Some  have  also  added  to 
this  argument  a  statement  that  a  fibrous  union,  under  any  circum- 
stances, is  inevitable,  and  that  it  is  a   matter  of  little  consequence 


312  FEACTUEES    OF    THE    ULNA. 

whether  the  ligament  thus  formed  is  long  or  short,  since  in  either  con- 
dition it  will  be  equally  serviceable. 

In  reply  to  these  statements,  it  may  be  said  briefly  that  they  are 
nearly  all  based  upon  false  premises,  or  that  they  have  been  proven  in 
themselves  to  be  essentially  erroneous. 

Anchylosis  is  always  a  serious  event,  which  by  all  possible  means 
the  surgeon  will  seek  to  prevent,  but  position  has  nothing  to  do  with 
determining  this  result ;  when  it  does  occur,  it  may  usually  be  ascribed 
either  to  the  severity  and  complications  of  the  original  injury,  to  the 
violence  of  the  consequent  inflammation,  or  to  having  neglected,  at  a 
proper  period,  and  with  sufficient  perseverance,  to  move  the  joint. 

That  a  fibrous  union  is  inevitable  under  any  circumstances,  has 
been  fully  proven  to  be  an  error ;  and  it  has  been  equally  proven 
that  the  functions  of  the  arm  are  generally  impaired  in  proportion  to 
the  length  of  the  uniting  medium. 

The  only  argument  which  remains,  and  which  really  possesses  any 
weight,  is,  that,  if  permanent  anchylosis  does  actually  occur,  the  arm, 
when  demi-flexed,  is  in  a  better  position  for  the  performance  of  its 
ordinary  functions ;  and  this,  considered  as  an  argument  in  favor  of 
the  universal  or  even  general  adoption  of  the  flexed  position,  is  suc- 
cessfully met  by  a  statement  of  the  infrequency  of  permanent  anchy- 
losis after  a  simple  fracture,  when  the  case  has  been  properly  treated, 
whether  by  the  flexed  or  straight  position  ;  while,  if  the  limb  is  flexed, 
a  maiming,  as  a  result  of  the  great  length  of  the  intermediate  liga- 
ment, is  almost  inevitable. 

Yet  if,  in  any  case,  from  the  great  severity  and  complications  of  the 
injury,  especially  in  certain  examples  of  compound  and  comminuted 
fracture,  it  were  to  be  reasonably  anticipated  that  permanent  bony 
anchylosis  must  result,  or  even  where  the  probabilities  were  strongly 
that  way,  the  surgeon  might  be  justified  in  selecting  for  the  limb,  at 
once,  the  position  of  demi-flexion;  or  he  might  leave  the  arm  without 
a  splint,  and  at  liberty  to  draw  up  spontaneously  and  gradually  to 
this  position,  as  it  is  always  very  prone  to  do. 

In  favor  of  moderate,  but  not  complete  extension,  it  is  claimed  that 
it  is  less  fatiguing  than  the  latter  position,  while  it  accomplishes  a 
more  exact  apposition  of  the  fragments,  if  they  happen  to  be  brought 
actually  into  contact. 

I  am  unable,  however,  to  understand  how  the  apposition  can  be 
rendered  less  exact  by  complete  extension,  unless  by  this  is  meant  a 
degree  of  extension  beyond  that  which  is  natural,  and  which,  I  am 
well  aware,  is  permitted  to  the  elbow-joint  when  this  posterior  brace 
is  broken  ofi".  It  would  certainly  derange  the  fragments  to  place  the 
arm  in  this  extreme  condition  of  natural  extension ;  indeed,  perhaps 
we  may  admit  that,  in  order  to  perfect  apposition,  the  extension  ought 
to  be  less  by  one  or  two  degrees  than  what  is  natural,  sufficient  to 
compensate  for  the  trifling  amount  of  effusion  which  may  be  presumed 
to  have  occurred  in  the  olecranon  fossa,  and  which  would  prevent  the 
process  from  sinking  again  fairly  into  its  fossa. 

As  to  its  being  less  fatiguing,  it  is  well  knov/n  to  those  accustomed 
to  treat  fractures  of  the  thigh  by  permanent  extension  that  the  muscles 


FEACTUEES    OF    THE    OLECEANOX    PEOCESS.  313 

rapidly  acquire  a  tolerance,  whicli  soon  dissipates  all  feeling  of  fatigue, 
and  that,  after  a  few  hours,  or  days  at  most,  the  patients  express  them- 
selves as  being  more  comfortable  in  this  position  than  in  the  flexed. 

Finally,  the  advocates  of  complete  extension  claim  that  in  this  posi- 
tion alone,  is  the  triceps  most  perfectly  relaxed,  and  consequently  the 
most  important  indication,  namely,  the  descent  of  the  olecranon,  most 
full}^  accomplished.  In  this  opinion  we  also  concur ;  and  regarding 
all  other  considerations,  in  the  early  days  of  the  treatment,  as  secondary 
to  this  one,  we  unhesitatingly  declare  our  preference  for  what  has 
been  called  the  "position  of  complete  extension," 

It  only  remains  for  us  to  determine  by  what  means  the  limb  can  be 
best  maintained  in  the  extended  position,  and  the  olecranon  process 
most  easily  and  eftectually  secured  in  place. 

For  this  purpose  a  variety  of  ingenious  plans  have  been  devised; 
such  as  the  compress  and  "  figure-of-8"  bandage  of  Duverney,  without 

Fig.  93, 


Sir  Astley  Cooper's  method. 

splints;  or  a  similar  bandage  employed  by  Desault,  with  the  addition 
of  a  long  splint  in  front ;  the  circular  and  transverse  bandages  of  Sir 
Astley  Cooper,  with  lateral  tapes  to  draw  them  together,  to  which 
also  a  splint  was  added;  and  man}^  other  modes  not  varying  essentially 
from  those  already  described,  but  nearly  all  of  which  are  liable  to  one 
serious  objection,  namely,  that  if  they  are  applied  with  sufficient  firm- 
ness to  hold  upon  the  fragment,  and  Boyer  says  they  "ought  to  be 
drawn  very  tight,"  they  ligate  the  limb  so  completely  as  to  interrupt 
its  circulation,  and  expose  the  limb  greatly  to  the  hazards  of  swelling, 
ulceration,  and  even  gangrene.  How  else  is  it  possible  to  make  the 
bandage  effective  upon  a  small  fragment  of  bone,  scarcely  larger  than 
the  tendon  which  envelops  its  upper  end,  and  with  no  salient  points 
against  which  the  compress  or  the  roller  can  make  advantageous 
pressure?  If,  then,  these  accidents,  swelling,  ulceration,  and  gan- 
grene, are  not  of  frequent  occurrence,  it  is  only  because  the  bandage 
has  not  been  generally  applied  "  very  tight,"  and  while  it  has  done  no 
harm,  it  has  as  plainly  done  no  good. 

The  dangers  to  which  I  allude  may  be  easily  avoided,  without  re- 
laxing the  security  afforded  by  the  compress  and  bandage,  by  a  method 
which  is  very  simple,  and  the  value  of  which  I  have  already  sufficiently 
determined  by  my  own  practice. 

The  surgeon  will  prepare,  extemporaneously  always,  for  no  single 
pattern  will  fit  two  arms,  a  splint,  from  a  long  and  sound  wooden 
shingle,  or  from  any  piece  of  thin,  light  board.  This  must  be  long 
enough  to  reach  from  near  the  wrist-joint,  to  within  three  or  four 
inches  of  the  shoulder,  and  of  a  width  equal  to  the  widest  part  of  the 


314 


FRACTDKES    OF    THE    ULNA. 


limb.  Its  width  must  be  uniform  throughout,  except  that,  at  a  point 
corresponding  to  a  point  three  inches,  or  thereabouts,  below  the  top 
of  the  olecranon  process,  there  shall  be  a.  notch  on  each  side,  or  a 
slight  narrowing  of  the  splint.     One  surface  of  the  splint  is  now  to  be 

Fig.  M. 


Fig.  95. 


The  author's  method. 


thickly  padded  with  hair  or  cotton-batting,  so  as  to  fit  all  of  the  in- 
equalities of  the  arm,  forearm,  and  elbow,  and  the  whole  covered  neatly 
with  a  piece  of  cotton  cloth,  stitched  together  upon  the  back  of  the 
splint.  Thus  prepared,  it  is  to  be  laid  upon  the  palmar  surface  of  the 
limb,  and  a  roller  is  to  be  applied,  commencing  at  the  hand  and  cover- 
ing the  splint,  by  successive  circular  turns,  until  the  notch  is  reached, 
from  which  point  the  roller  is  to  pass  upwards  and  backwards  behind 
the  olecranon  process  and  down  again  to  the  same  point  on  the  oppo- 
site side  of  the  splint ;  after  making  a  second  oblique  turn  above  the 
olecranon,  to  render  it  more  secure,  the  roller  may  begin  gradually  to 
descend,  each  turn  being  less  oblique,  and  passing  through  the  same 
notch,  until  the  whole  of  the  back  of  the  elbow-joint  is  covered.  This 
completes  the  adjustment  of  the  fragments,  and  it  only  remains  to 
carry  the  roller  again  upwards,  by  circular  turns,  until  the  whole  arm 
is  covered  as  high  as  the  top  of  the  splint. 

The  advantage  of  this  mode  of  dressing  must  be  apparent.  It  leaves, 
on  each  side  of  the  splint,  a  space  upon  which  neither  the  splint  nor 
bandage  can  make  pressure,  and  the  circulation  of  the  limb  is,  there- 
fore, unembarrassed,  while  it  is  equally  effective  in  retaining  the  ole- 
cranon in  place,  and  much  less  liable  to  become  disarranged. 

Before  the  bandage  is  applied  about  the  elbow-joint,  the  olecranon 
must  be  drawn  down,  as  well  as  it  can  be,  by  pressure  with  the  fingers, 
and  a  compress  of  folded  linen,  wetted  to  prevent  its  sliding,  must  be 
placed  partly  above  and  partly  upon  the  process;  at  the  same  time, 
also,  care  must  be  taken  that  the  skin  is  not  folded  in  between  the 
fragments. 

This  dressing  ought,  no  doubt,  to  be  applied  immediately,  since,  if 
we  wait,  as  Boyer  seems  to  advise,  until  the  swelling  has  subsided,  it 
will  be  found  much  more  difficult  to  straighten  the  arm  completely 


FEACTUEES  OF  THE  OLECEANON  PEOCESS.       315 

than  it  would  have  been  at  first,  and  the  olecranon  process  will  be  more 
drawn  up  and  fixed  in  its  abnormal  position.  Something  will  be 
gained  by  these  means,  adopted  early,  even  if  the  bandage  cannot  be 
applied  tightly,  and  moderate  bandaging  will  not  in  any  way  interfere 
with  the  proper  and  successful  treatment  of  the  inflammation.  We 
must  always  keep  in  mind,  however,  the  fact  that  the  fracture  being 
usually  the  result  of  a  direct  blow,  considerable  inflammation  and 
swelling  about  the  joint  are  about  to  follow  rapidly ;  and  on  each  suc- 
cessive day,  or  oftener  if  necessary,  the  bandages  must  be  examined 
carefully,  and  promptly  loosened  whenever  it  seems  to  be  necessary. 
For  this  purpose  it  is  better  not  to  unroll  the  bandages,  but  to  cut 
them  with  a  pair  of  scissors,  along  the  face  of  the  splint,  cutting  only 
a  small  portion  at  a  time,  and  as  they  draw  back,  stitch  them  together 
again  lightly ;  and  thus  proceed  until  the  whole  has  been  rendered 
sufficiently  loose. 

As  soon  as  the  inflammation  has  subsided,  and  as  early  sometimes 
as  the  fifth  or  seventh  day,  the  dressings  ought  to  be  removed  com- 
pletely; and  while  the  fingers  of  the  surgeon,  resting  upon  a  compress, 
sustain  the  process,  the  elbow  ought  to  be  gently  and  slightly  flexed 
and  extended  two  or  three  times.  From  this  time  forward,  until  the 
union  is  consummated,  this  practice  should  be  continued  daily,  only 
increasing  the  flexion  each  time,  as  the  inflammation  and  pain  may 
permit.  If  it  is  thought  best,  at  length,  to  change  the  angle  of  the 
arm,  and  to  flex  it  more  and  more,  it  may  be  done  easily  by  substi- 
tuting a  very  thick  sheet  of  gutta  percha  for  the  board. 

Dieffenbach  has  several  times,  in  old  fractures  of  both  the  olecranon 
and  patella,  where  the  fragments  were  dragged  far  apart,  divided  the 
tendons,  so  as  to  be  able  to  bring  the  two  portions  together,  and,  by 
friction  of  them  one  upon  the  other,  has  endeavored  to  excite  such 
action  as  might  end  in  the  formation  of  a  shorter  and  a  firmer  bond  of 
union.  In  some  instances,  it  is  said,  considerable  benefit  was  obtained, 
after  all  other  means  had  failed ;  in  others,  the  result  was  negative. 
One  example  of  an  old  ununited  fracture  of  the  olecranon  is  mentioned, 
in  which  he  divided  the  tendon  of  the  triceps,  secured  the  upper  frag- 
ment in  place,  and  every  fourteen  days  rubbed  it  well  against  the 
lower  one;  in  three  months  "the  union  was  firm."^ 

The  practice,  not  without  its  hazards,  needs  further  observations  to 
determine  its  value. 

'  Dieffenbach,  American  Journal  of  Medical  Science,  vol.  xxix.  p.  478  ;  from  Casper's 
Wochensclirift,  Oct.  2d,  1841. 


316 


FRACTURES  OF  THE  RADIUS  AND  ULNA. 


CHAPTER    XXIII 


FRACTURES  OF  THE  RADIUS  AND  ULNA. 


Causes. — In  a  large  majoritj?'  of  the  examples  of  this  fracture  seen 
by  me,  which  have  been  of  such  a  character  as  to  warrant  an  attempt 
to  save  the  limb,  the  accident  has  been  occasioned  by  a  fall  upon  the 
palm  of  the  hand  while  the  arm  was  extended  in  front  of  the  body. 
Yet  this  cause  is  not  so  constant  as  in  fractures  of  the  radius  alone, 
since  a  considerable  number  have  been  occasioned  by  direct  blows ; 
and  if  we  were  to  add  to  this  estimate  all  of  those  bad  compound  frac- 
tures which  have  demanded  immediate  amputation,  the  proportion  of" 
fractures  occasioned  by  direct  and  indirect  blows  might  be  found  to  be 
pretty  nearly  balanced. 

Point  of  Fracture,  Character,  Direction  of  Displacement,  <&c. — In  a 
record  of  fifty-three  fractures  of  both  bones,  I  have  noticed  but  two 
examples  in  the  upper  third ;  while  I  have  found  that  twenty-one 
happened  in  the  middle  third,  twenty-eight  in  the  lower  third;  and 


Fig.  96. 


Fig.  97. 


Fracture  in  the  middle  third. 


in  one  case  the  radius  was  broken  three-quarters  of  an 
inch  above  its  lower  end,  and  the  ulna  about  one  inch 
below  the  coronoid  process.  Three  of  the  fractures 
belonging  to  the  lower  third  were  probably  epiphyseal 
separations. 

Forty-four  were  in  males,  and  nine  in  females.  Nineteen 
are  known  to  have  occurred  in  the  right  arm  and  thirteen 
in  the  left. 

Forty-one  were  simple,  seven  compound,  one  was  com- 
minuted, three  both  compound  and  comminuted,  one 
complicated  with  a  fracture  of  the  humerus,  and  one 
with  a  partial  luxation  of  the  lower  end  of  the  radius. 
With  three  exceptions,  all  of  these  more  serious  accidents 
were  arranged  among  fractures  of  the  lower  third,  and 
generally  the  bones  had  been  broken  near  the  wrist. 

Partial  fractures  have  been  frequently  observed,  but  having  treated 


Fracture  in  the 
lower  third. 


FEACTURES  OF  THE  RADIUS  AND  ULNA. 


317 


Fig.  98. 


of  these  fractures  fully  in  another  chapter,  I  shall  not  think  it  neces- 
sary to  make  any  further  allusion  to  them  in  this  place. 

Prognosis. — Generally  these  bones  unite  in  from  twenty  to  thirty 
days;  but  I  have  seen  the  union  occasionally  delayed  considerably 
beyond  this  time,  and  this  delay  has  occurred  especially  in  the  case 
of  the  radius.  Thus,  in  three  cases  of  compound  and  comminuted 
fracture,  the  ulna  united  within  four  or  five  weeks,  while  the  radius 
did  not  unite  until  the  ninth  or  tenth  week.  Twice  in  simple  fractures 
the  ulna  has  united  in  the  usual  time,  but  the  radius  not  until  the 
sixteenth  week.  Once  the  ulna  has  united  promptly  and  the  radius 
remained  ununited  at  the  end  of  two  years,  at  which  time  I  practised 
resection  of  the  broken  ends  of  the  radius,  and  union  was  speedily 
established. 

On  the  other  hand  I  have  once  seen  the  union  delayed  four  months 
in  the  case  of  the  ulna,  when  the  radius  had  united  in  the  usual  time; 
and  in  one  example  of  compound  fracture  both  bones 
refused  to  unite  until  after  the  fifth  month. 

Thirty-two  of  the  whole  number  have  united  with- 
out any  appreciable  deformity,  and  twelve  are  known 
to  have  left  some  marked  defect,  while  two  have  re- 
sulted finally  in  the  loss  of  the  arm. 

I  have  seen  the  fragments  deviate  slightly  in  almost 
every  direction,  but  most  often  it  has  been  noticed 
that  the  deviation  was  to  the  radial  or  ulnar  sides. 
Thus,  in  three  examples,  two  of  which  had  been 
compound  fractures,  the  bones  have  united  in  such  a 
position  as  that  from  the  point  of  fracture  doAvnwards 
the  forearm  has  been  deflected  to  the  ulnar  side,  and 
a  marked  projection  has  been  left  at  the  seat  of  frac- 
ture on  the  radial  side;  while  in  two  examples,  both 
of  which  were  simple  fractures,  exactly  the  opposite 
condition  has  obtained,  the  lower  part  of  the  forearm 
being  deflected  to  the  radial  side. 

In  a  majority  of  cases  the  hand  has  been  left  with 
some  tendency  to  pronation ;  in  many  instances  this 
tendency  was  very  slight  and  scarcely  appreciable, 
but  in  others  it  has  been  quite  marked,  so  that  the 
patients  have  been  wholly  unable  to  supine  the  fore- 
arm except  by  a  motion  of  the  humerus  in  its  socket. 

From  what  has  been  said  it  must  be  seen  that  the 
prognosis  in  these  accidents  takes  the  widest  range:  for  while  a  larger 
proportion  than  in  the  case  of  almost  any  other  of  the  long  bones, 
unite  without  any  appreciable  deformity,  a  considerable  number  delay 
to  unite  or  do  not  unite  at  all,  and  some,  even  where  the  fracture 
is  most  simple,  result  in  the  complete  loss  of  the  limb.  I  am  not  now 
speaking  of  those  more  severe  accidents  in  which  the  limb  is  at  once 
condemned  to  amputation,  and  which,  in  the  case  of  the  arm,  are 
numerous;  but  as  I  have  already  mentioned,  our  observations  here 
apply  only  to  cases  which  came  under  treatment  with  a  view  especially 
to  the  fracture. 


m 


Union   with   slight 
lateral  displacement. 


318  FEACTUEES    OF    THE    EADIDS    AND    ULNA. 

I  shall  state  the  facts  more  fully,  and  then  perhaps  we  shall  think 
it  proper  to  inquire  why,  when,  as  a  rule,  the  treatment  is  found  to  be 
so  simple  and  successful,  occasionally,  and  pretty  often  indeed,  it  re- 
sults so  disastrously. 

A  boy,  aged  about  ten  years,  fell  from  a  tree,  April  22,  1856,  frac- 
turing the  right  forearm  near  the  lower  end  of  the  middle  third.  It 
was  evident  that  he  had  fallen  upon  the  palm  of  his  hand,  as  the  lower 
fragments  were  inclined  backwards,  and  one  of  the  bones  had  been 
thrust  through  the  skin  on  the  front  of  the  arm. 

It  was  at  first  dressed  carefully  by  Dr.  Wilcox,  but  the  father  of  the 
lad  on  the  following  day  placed  him  under  the  care  of  an  empiric. 

Six  days  after  the  fracture  occurred,  I  was  called  to  see  him,  with 
several  other  gentlemen.  He  was  then  suffering  under  a  severe  attack 
of  tetanus  which  had  commenced  the  night  before.  His  arm  was 
much  swollen  and  very  painful.     He  died  the  same  evening. 

I  was  unable  to  learn  very  particularly  what  had  been  the  treat- 
ment since  the  patient  was  seen  by  Dr.  Wilcox,  except  that  the  band- 
ages had  been  most  of  the  time  very  tight,  and  that  the  doctor  had 
applied  stimulating  liniments,  the  boy  constantly  complaining  greatly 
of  the  pain.  I  found  the  arm  done  up  in  a  most  slovenly  manner 
with  several  narrow  splints,  underlaid  with  loose  and  knotty  fragments 
of  cotton  batting. 

We  removed  all  of  these  immediately,  and  laid  the  arm  upon  a 
cushion  supported  by  a  board,  to  both  of  which  the  arm  was  lightly 
secured  by  a  few  turns  of  a  bandage;  cool  water  lotions  were  dili- 
gently applied  and  chloroform  administered  by  inhalation ;  but  the 
fatal  event  was  delayed  only  a  few  hours. 

I  shall  not  stop  to  inquire  the  cause  of  a  result  so  unfortunate, 
where  the  treatment  has  been  so  palpably  unskilful. 

I  have  already  mentioned  one  case  of  gangrene  of  the  hand,  after 
a  fracture  of  the  lower  part  of  the  humerus;  Norris,  in  a  note  to  the 
American  edition  of  Listorts  Surgery^  mentions  a  case  which  came 
under  his  observation  in  the  Pennsylvania  Hospital,  the  fracture  hav- 
ing taken  place  just  above  the  condyles,  and  still  another  has  been 
related  to  me  lately.  I  have  brought  together  also  no  less  than  five 
cases  of  sloughing  of  the  arm,  after  fracture  of  the  radius,  and  one  of 
sloughing  from  tight  bandaging,  where  the  radius  was  supposed  to  be 
broken,  although  the  dissection  proved  that  it  was  not. 

Robert  Smith  says,  that  similar  cases  have  been  recorded  in  the 
Gazette  Medicale.  To  these  I  shall  now  add  two  examples  of  sloughing 
after  fracture  of  both  radius  and  ulna;  making  a  total  of  eleven  cases 
in  the  upper  extremities,  in  addition  to  those  reported  in  the  Gazette 
Medicale^  an  exact  account  of  which  I  have  not  seen. 

John  McGrath,  set.  9,  fell,  July  2,  1847,  from  a  ladder,  about  thirty 
feet  to  the  ground,  breaking  the  right  radius  and  ulna  in  their  middle 
thirds.  A  surgeon,  residing  in  this  city,  was  in  attendance  about  four 
or  five  hours  after  the  accident  occurred.  He  then  reduced  the  frac- 
tures and  applied  two  broad  splints,  one  on  the  palmar  and  one  on  the 
dorsal  surface  of  the  forearm.     Whether  a  roller  was  first  applied  to 


FRACTURES  OF  THE  RADIUS  AND  ULNA.        319 

the  arm,  or  not,  I  am  unable  to  say.  The  splints  were  secured  in 
place  by  a  roller  and  the  arm  laid  in  a  sling. 

The  third  day  "was  our  national  holiday,  and  the  patient  was  not 
visited.  Nor  was  he  seen  on  the  fourth  day,  not  being  found  at  home. 
On  the  fifth  day  the  surgeon  removed  the  bandages  and  found  the  arm 
gangrenous ;  and  within  an  hour  afterwards  I  was  requested  to  see  it 
also. 

I  found  him  lying  in  a  miserable  apartment,  with  his  right  arm 
resting  upon  a  pillow.  The  arm,  forearm,  and  hand  were  gangrenous 
through  their  whole  extent;  and  the  skin  of  the  right  side,  on  the 
front  of  the  chest,  had  assumed  a  dusky  color,  the  extreme  margin  of 
which  was  indicated  by  an  abrupt  crescentic  line.  The  thumb  and 
fingers  were  black.  His  countenance  was  bright  and  cheerful,  and 
his  mind  intelligent;  pulse  75,  and  soft;  tongue  clean.  He  had  slept 
undisturbed  the  night  before,  and  he  had  all  along  felt  perfectly  well, 
except  that  he  had  a  slight  diarrhoea.  I  was  assured  by  the  surgeon 
and  by  all  of  the  family,  that  the  bandages  had  not  been  applied 
tightly  ;  but  we  were  told  that  on  the  third  day  of  the  accident,  having 
been  locked  into  the  house  by  his  mother,  who  was  a  pedler,  he 
climbed  out  of  the  window,  and  that  during  all  of  that,  and  most  of 
the  following  day  he  was  running  about  the  streets  firing  crackers, 
during  most  of  which  time  his  arm  was  removed  from  his  sling  and 
hanging  by  his  side.  On  the  morning  of  the  fourth  day,  his  mother 
noticed  that  his  fingers  were  black,  but  she  thought  they  were  stained 
with  powder. 

We  ordered  him  to  take  one-quarter  of  a  grain  of  opium  every 
four  hours,  and  applied  a  yeast  poultice  to  the  arm.  On  the  seventh 
day  the  gangrene  was  still  extending,  and  the  pulse  was  12i;  yet  he 
continued  to  feel  well  and  to  eat  as  usual.  On  the  tenth  day,  the  line 
of  demarcation  had  commenced  opposite  the  shoulder-joint ;  and  the 
crescentic  discoloration  on  the  breast,  which  had  at  first  spread  rapidly 
until  it  covered  nearly  the  whole  upper  half  of  the  chest,  was  quite 
faint,  in  some  parts  almost  lost. 

In  a  few  days  more  he  was  removed  to  the  county  almshouse,  the 
separation  continuing  rapidly  to  take  place  until  the  arm  fell  off  at 
the  shoulder-joint ;  after  which  he  made  a  good  recovery. 

A  child  two  years  and  three  months  old,  had  fallen  from  a  chair 
upon  the  floor,  a  distance  of  about  two  feet.  A  German  physician 
being  called,  found,  as  he  believes,  a  fracture  of  both  bones  of  the  left 
arm.  The  fracture  was  near  the  middle.  He  immediately  applied  a 
roller  from  the  fingers  to  the  elbow,  and  over  this  three  narrow  splints 
made  of  the  wood  of  a  cigar  box.  One  of  these  was  laid  upon  the 
palmar,  one  upon  the  dorsal,  and  one  upon  the  radial  side  of  the  fore- 
arm, and  the  whole  were  bound  together  by  another  roller.  From 
this  time  until  the  tenth  day  the  child  continued  to  play  about  on  the 
floor.  Ten  days  after  the  accident  occurred  the  doctor  noticed  that 
the  ulnar  side  of  the  little  finger  was  blue.  The  bandages  were  im- 
mediately removed,  and  were  never  again  applied  tightly. 

Three  or  four  days  after  I  was  requested  to  see  the  arm  with  the  at- 
tending physician.    The  gangrene  had  continued  to  extend,  involving 


320  FEACTURES    OF    THE    RADIUS    AND    ULNA. 

now  the  whole  of  the  little  finger  and  most  of  the  thunab.  There 
were  also  gangrenous  spots  over  the  hand  and  forearm,  extending  to 
within  one  inch  from  the  elbow-joint;  these  spots  were  more  numerous 
in  front  and  on  the  back  of  the  forearm,  and  seemed  to  correspond  to 
the  pressure  of  the  splints.  The  hand  was  much  swollen,  and  also 
the  arm  above  the  line  of  the  gangrene.  The  sloughs  had  already 
commenced  to  be  thrown  off,  and  the  gangrene  was  only  extending 
in  a  few  points.  The  child  appeared  well  and  rather  playful,  except 
when  the  arm  was  being  dressed. 

I  ordered  a  yeast  poultice,  and  a  nourishing  diet. 

I  have  since  learned  that  the  arm  and  a  large  portion  of  the  hand 
were  finally  saved. 

South  also  says  that  he  has  seen  one  or  two  instances  of  mortifica- 
tion produced  by  splints  applied  too  tightly,  and  previous  to  the 
accession  of  the  swelling  after  fracture,  and  which  have  not  been 
loosened  as  the  swelling  increased.^ 

How  shall  we  explain  the  frequency  of  these  accidents  after  fracture, 
especially  of  the  forearm  ? 

Malgaigne,  speaking  of  fractures  of  both  bones  of  the  forearm,  re- 
marks that  "  when  the  displacement  is  considerable,  or  more  especially 
when  the  outward  violence  has  been  excessive,  we  frequentl}''  see  follow 
a  very  intense  inflammatory  swelling,  and  there  is  no  fracture  which 
complicates  itself  so  easily  with  gangrene  under  the  pressure  of  appa- 
ratus."^ 

Says  N^laton  :  "If  we  make  choice  of  the  apparatus  of  J.  L.  Petit, 
it  is -necessary  that  it  shall  not  be  applied  too  tightly,  for,  as  Professor 
Eoux  has  long  since  remarked,  fractures  of  the  forearm  are  those 
which  furnish  most  of  the  examples  of  gangrene  in  consequence  of 
an  arrest  of  the  circulation.  This  is  easily  understood,  if  we  consider 
on  the  one  hand  the  superficial  position  of  the  two  principal  arteries 
of  the  forearm,  and  on  the  other  the  disposition  of  the  appareil,  which 
must  almost  infallibly  compress  the  arteries  to  a  great  extent."^ 

I  do  not  think  that  this  accident  is  due  always  to  the  negligence  of 
the  surgeon.  It  may  be  due  many  times  to  the  carelessness  of  the 
parents  or  of  the  patient  himself;  as  in  the  case  of  the  boy  who  came 
under  my  own  observation,  and  who  lost  his  arm  at  the  shoulder- 
joint.  Sometimes  also  it  may  be  due  rather  to  the  severity  of  the 
original  injury,  which,  the  experience  of  every  surgeon  will  pi'ove,  is 
occasionally  competent  to  the  production  of  such  bad  results.  A 
number  of  unfortunate  circumstances  may  have  concurred,  such  as  a 
severe  injury,  especially  where  the  skin  has  remained  unbroken  and 
the  effused  blood  has  had  no  opportunity  to  escape — the  broken  bone 
may  have  rested  against  the  trunk  of  a  main  artery  causing  an  arrest 
of  its  circulation — the  constitution  may  be  impaired  by  previous  ill- 
ness, or  it  may  be  suffering  under  the  shock  of  the  injury;  yet  that  it 
may  be  and  too  often  is  the  result  of  maltreatment,  on  the  part  of  the 
surgeon,  is  undeniable.     It  is  proper,  however,  to  discriminate  between 

1  South,  note  to  Chelius's  Surg.,  vol.  i.  p.  69. 
^  Malgaigne,  Frac.  et  Disloc,  torn.  i.  p.  589. 
3  Nelaton,  Patiiologie  Chirurgicale,  p.  735. 


FKACTURES    OF    THE    RADIUS    AND    ULNA.  821 

the  responsibility  which  attaches  to  the  surgeon  as  the  true  exponent 
of  the  state  of  his  art,  and  that  which  attaches  to  the  art  itself  as 
taught  by  the  masters. 

The  old  surgeons  applied  first  a  roller  to  the  hand  and  forearm,  and 
over  this  their  various  splints.  J,  L.  Petit  thought  he  had  made 
a  valuable  improvement  upon  this  simple  plan  in  laying  over  the 
roller  a  compress,  supported  by  a  splint,  designed  to  press  between  the 
bones,  and  to  antagonize  thus  the  action  of  the  roller  in  drawing  the 
fragments  toward  each  other.  Daverney  believed  that  this  object 
would  be  best  accomplished  by  placing  the  pad  against  the  skin,  and 
under  a  circular  compress;  while  Desault  declares  all  of  these  modes 
inefficient,  and  announces  a  method  which  he  regards  as  accomplishing 
at  once  and  completely  all  of  the  indications;  the  sole  peculiarity  of 
which  method  consists  in  placing  the  graduated  pads  against  the  skin, 
and  securing  them  in  place  by  a  roller.  Boyer  adopts  the  same  method 
without  any  modifications,  and  Mr.  Hind,  in  his  illustrations  of  frac- 
tures already  referred  to,  has  seen  fit  to  recommend  the  same,  at  least 
in  fractures  of  the  radius. 

It  is  quite  obvious  that  between  these  various  methods  there  remains 
very  little  if  anything  to  choose,  the  dift'erences  being  too  trifling  and 
unessential  to  claim  serious  consideration.  Each  alike  is  inadequate 
to  accomplish  any  amount  of  useful  pressure  between  the  fragments; 
each  alike  is  calculated  to  bind  the  bones  one  against  the  other,  and 
each  alike  exposes  to  the  danger  of  ligation  and  of  gangrene. 

Says  M.  Dupuytren:  "The  practice  of  rolling  the  arm  before  the 
splints  are  applied,  whether  internal  or  external  to  the  pads  and  com- 
presses, is  eminently  mischievous;  and  instead  of  fulfilling,  directly 
counteracts,  the  indications  which  it  is  most  important  to  keep  in  view 
in  the  treatment  of  fractures  of  the  forearm." 

And  notwithstanding  the  same  sentiment  has  been  reiterated  by 
Velpeau,  Malgaigne,  Nelaton,  Samuel  Cooper,  Bransby  Cooper, 
Erichseu,  Amesbury,  Gibson  and  others,  yet  we  find  to-day  the  great 
surgeon  of  Heidelburgh,  Chelius,  recommending  the  roller  to  be 
applied  under  the  splints,  after  the  manner  of  Desault:  while  Liston, 
Syme,  and  Fergusson,  who  perhaps  represent  the  Edinburgh  school, 
use  only  pasteboard  splints  above  the  compresses,  over  which  is  im- 
mediately applied  the  roller;  a  practice  which  differs  very  little  from 
that  recommended  by  Desault,  and  is  equally  obnoxious  to  criticism. 

Among  the  American  surgeons,  I  believe,  the  advice  and  practice  of 
Dupuytren  have  received  almost  universal  assent,  only  that  we  have 
always  employed  splints  much  wider  than  those  recommended  by 
this  distinguished  surgeon.  I  cannot  therefore  agree  with  my  accom- 
plished countryman.  Dr.  Reynell  Coates,  if  in  the  following  para- 
graph he  means  to  imply  that  American  surgeons  generally  adopt 
Desault's  treatment.  Such  at  least  is  not  my  experience.  "  It  would 
be  wrong,"  says  Dr.  Coates,  "not  to  bear  testimony,  on  every  possi- 
ble occasion,  against  the  folly  so  universally  prevalent,  that  induces 
surgeons  to  apply  a  bandage  directly  to  the  forearm  before  applying 
splints  in  injuries  of  this  character.  We  have  often  asked  for  a  ra- 
tional explanation  of  this  practice,  without  effect.  It  is  directly  at 
21 


322        FEACTURES  OF  THE  EADIUS  AND  ULNA. 

war  with  the  acknowledged  iudications  in  the  coaptation  of  the  frag- 
ments, and  when  the  object  of  the  whole  apparatus  is  to  thrust 
asunder  their  extremities,  it  commences  by  binding  them  together. 
Few. plans  in  surgery  are  more  generally  followed;  none  can  be  more 
absurd." 

Of  the  estimate  placed  upon  the  roller  by  M.  Mayor,  the  reader 
will  judge  by  a  reference  to  the  passage  which  I  shall  quote  further 
on,  when  I  shall  speak  of  the  value  of  the  interosseous  compresses. 

Amesbury  and  Bransby  Cooper  use  no  rollers  at  all — not  even  to 
secure  the  splints  in  place,  they  being  made  fast  to  the  forearm  by 
straps  or  tapes;  a  practice  which,  I  am  happy  to  say,  has  found  hitherto, 
except  perhaps  among  the  English,  very  few  followers. 

Mr.  Amesbury  and  Mr.  South  also  endeavor  to  give  to  their  splints 
an  appropriate  shape,  by  having  them  constructed  with  more  or  less 
convexity.  It  must  be  noticed,  however,  that  the  practice  of  these 
two  gentlemen  is  very  dissimilar,  for  while  Mr.  South  applies  the 
convex  surface  of  his  splint  to  the  interosseous  space,  Mr.  Amesbury 
reverses  this  plan,  and  applies  the  concave  suriface  directly  to  the  skin. 

As  to  the  width  of  the  splints,  surgeons  are  also  very  generally 
agreed,  at  the  present  day,  that  they  ought  to  be  at  least  wider  than 
the  arm,  so  as  to  prevent  the  roller  or  the  tapes  from  resting  against 
its  sides. 

I  do  not  intend  to  deny  peremptorily,  and  without  qualification,  the 
value  of  the  graduated  compresses,  which,  as  we  have  seen,  are  usually 
laid  along  the  interosseous  space  to  press  the  fragments  asunder.  It 
is  necessary,  however,  to  caution  the  surgeon  against  their  injudicious 
use.  M.  N^laton  has  well  remarked  of  the  apparel  employed  b}''  J. 
L.  Petit,  that  it  must  inevitably  compress,  to  a  great  extent,  the 
arteries  of  the  forearm ;  and  the  remark  is  applicable,  in  only  a  less 
degree,  to  all  of  those  other  plans  in  which  the  compress  is  employed. 
And  I  suspect  that  to  this  portion  of  the  dressing,  quite  as  much  as  to 
any  other  cause,  are  due  those  frightful  accidents  of  which  we  have 
already  spoken.  The  arteries  are  not  only  exposed,  from  their  super- 
ficial position,  to  pressure  from  a  compress,  but,  in  addition  to  this,  it 
will  be  noticed  that  the  two  principal  arteries,  the  radial  and  the  ulnar, 
are  situated  upon  a  broad  and  flat  surface  of  bone,  along  which  this 
pressure  must  operate  most  advantageously.  So  early  as  the  year 
1833,  M.  Lenoir,  in  his  inaugural  thesis,  at  Paris,  called  attention  to 
this  danger,  and  from  time  to  time  surgeons  have  continued  to  advert 
to  it,  but  they  have  seldom  given  to  its  consideration  that  prominence 
which  its  importance  deserves. 

I  have  observed  another  fact  in  this  connection :  when  this  compress 
is  extended  low  down  on  the  palmar  surface,  within  an  inch  or  two  of 
the  wrist-joint,  it  soon  becomes  excessively  painful,  and  sometimes 
even  wholly  insupportable,  in  consequence  of  the  pressure  made  upon 
the  median  nerve ;  and  I  find  myself  always  obliged  to  exercise  great 
care  in  the  adaptation  of  the  pads  at  this  point.  For  this  reason  alone 
I  believe,  in  case  of  a  fracture  near  the  base  of  the  radius,  the  lower 
fragment,  if  it  were  thrown  toward  the  ulna,  could  not  be  retained  in 
its  place  by  graduated  compresses. 


FRACTURES    OF    THE    RADIUS    AND    ULNA.  323 

In  short,  finding  that  broad  splints,  properly  covered  and  padded, 
answer  very  well  to  crowd  the  muscles  into  the  interosseous  space,  so 
far  as  it  is  proper  to  do  so,  and  believing  that  this  mode  is  less  painful 
and  less  dangerous,  I  seldom  resort  to  graduated  compresses,  nor  can 
I  appreciate  their  necessity,  or,  indeed,  their  utility.  Mr.  Lonsdale 
also  concurs  with  me  in  attaching  very  little  value  to  this  part  of  the 
accustomed  apparel. 

But  listen  to  the  surgeon  of  Lausanne,  M.  Mayor:  "  What  signify 
graduated  compresses  placed  between  the  bones  of  the  forearm  for 
the  purpose  of  separating  them  from  each  other  ?  These  bones  will 
not  have  that  constant  tendency  to  approach  each  other  which  has 
been  supposed,  provided,  first,  that  they  have  been  well  reduced; 
second,  that  for  the  purpose  of  maintaining  them  in  position  we  do 
not  make  use  of  a  preliminary  circular  bandage,  whose  action  is  an 
absurdity ;  and  in  short,  provided  we  make  the  retentive  means  act 
chiefly  upon  the  palmar  and  dorsal  surfaces  of  the  forearm.'" 

M.  Mayor  proceeds  to  declare  these  convictions  to  be  the  result  of 
his  own  experience,  both  in  the  treatment  of  simple  and  compound 
fractures  of  the  forearm,  and  he  intimates  that  in  the  use  of  the  cir- 
cular bandage  with  compresses,  surgeons  seem  to  have  rolled  the  arm 
into  a  cylinder  and  drawn  the  bones  together,  in  order  that  they 
might  tax  their  ingenuity  to  discover  some  means  to  again  separate 
them. 

Surgeons  have  generally,  after  the  splints  have  been  applied,  placed 
the  forearm  in  a  position  of  semi-pronation,  or  midway  between  su- 
pination and  pronation,  so  that  the  radius  should  be  uppermost ;  it 
being  assumed  that  in  this  position  the  two  bones  are  most  nearly  par- 
allel, and  least  inclined  to  displacement.  Such,  indeed,  was  the  prac- 
tice of  Hippocrates,  Paulus  jEgineta,  Celsus,  Albucasis,  and  of  most 
surgeons  down  to  this  day ;  but  Lonsdale,  Eobert  Smith,  Nelaton  and 
South  have  lately  called  in  question  the  correctness  of  this  mode  of 
dressing,  at  least  when  it  is  adopted  as  a  universal  rule. 

I  have  before  mentioned,  when  treating  of  fractures  of  the  ulna, 
that  M.  Fleury  had,  in  one  instance,  been  unable  to  bring  the  .frag- 
ments into  apposition  except  by  forced  supination  of  the  forearm  ; 
and  in  certain  fractures  we  have  seen  the  same  position  recommended 
by  Lonsdale. 

Says  Mr.  South,  in  a  note  to  Chelius :  "  In  fractures  of  both  bones 
the  forearm  is  best  laid  supine;"  and  Kelaton  declares  that  in  fractures 
of  the  radius  and  ulna  at  any  point  of  their  upper  thirds  it  will  be 
necessary  to  supine  the  arm,  both  in  the  reduction  and  during  the  sub- 
sequent treatment;  but  that  in  fractures  of  the  inferior  two-thirds 
we  may  place  the  limb  in  a  condition  of  semi-pronation. 

It  seems  very  probable,  however,  that  both  of  these  gentlemen  have 
received  their  suggestions  from  Mr.  Lonsdale,  who,  as  we  have  already 
seen,  has  treated  the  question  very  much  at  length,  and  who  has  finally 
declared  his  decided  preference  for  the  supine  position  in  the  treatment 

'  Bandages  et  Appareils  k  Pansements,  ou  Xouveau  Systeme  de  Deligation  Chirur- 
gicale,  par  M.  Mathias  Mayor,  Chirurg.  en  Chef  de  I'Hupital  de  Lausanne,  Switzer- 
land.    Paris  ed.  1  38,  p.  345. 


324  FEACTUKES    OF    THE    RADIUS    AND    ULNA. 

of  all  fractures  of  the  forearm.  His  arguments  are  certainly  very  inge- 
nious, and  as  applied  to  fractures  of  the  radius  above  the  insertion  of  the 
pronator  radii  teres,  they  seem  altogether  conclusive ;  and,  indeed, 
they  commend  themselves  very  strongly  to  our  judgment,  as  applied  to 
all  fractures  of  the  forearm.  They  are  sustained  also  by  the  results  of 
his  own  experience,  and  I  see  no  good  reason  why  they  should  not  be 
more  thoroughly  examined  and  tested  by  other  surgeons.  The  advan- 
tages which  he  claims  for  this  method  are  more  perfect  coaptation  of 
the  broken  ends,  less  liability  of  the  fragments  to  encroach  upon  the 
interosseous  space,  and  consequently  less  danger  of  anchylosis  between 
the  bones,  and  of  non-union  of  the  fragments,  more  complete  restora- 
tion of  the  power  of  supination,  and  less  tendency  to  lateral  distortion, 
or  of  falling  off  to  the  ulnar  or  radial  sides. 

My  own  cases,  treated  by  the  usual  method,  have  shown  that  while 
supination  is  frequently  impaired,  and  sometimes  entirely  lost,  prona- 
tion is  rarely  affected  ;  and  that  lateral  displacements  are  much  more 
common  than  displacements  forwards  or  back.wards.  How  this  posi- 
tion, semi-pronation,  may  tend  to  the  production  of  a  permanent  pro- 
nation, I  have  fully  explained  when  speaking  of  fractures  of  the 
head  of  the  radius;  and  the  influence  of  the  same  position,  the  fore- 
arm resting  upon  its  ulnar  margin  in  the  sling,  in  the  production  of  a 
lateral  deviation  is  also  easily  understood.  If  the  arm  rests  upon  the 
sling  so  that  its  weight  bears  more  upon  the  point  of  fracture  than 
upon  the  extremities  of  the  bones,  then  the  ulna,  or  both  ulna  and 
radius,  will  incline  gradually  to  the  radial  side,  and  the  hand  will  fall 
off'  to  the  ulnar  side ;  or  if  the  sling  rests  under  the  wrist  or  hand 
chiefly,  the  hand  will  ascend  to  the  radial  side,  and  the  broken  ends  of 
the  two  bones  will  project  to  the  ulnar  side. 

If  this  plan  is  adopted,  viz :  laying  the  hand  and  forearm  upon  its 
back,  instead  of  upon  its  ulnar  margin,  the  elbow  should  remain  at 
the  side,  the  humerus  falling  perpendicularly  from  its  socket ;  and  the 
forearm  should  rest  in  the  sling  directed  forwards  from  the  body.  Or, 
if  it  is  found  impossible  or  inconvenient,  owing  to  the  resistance  of 
the  pronator  muscles,  to  supine  the  arm  while  it  is  suspended  in  a 
sling,  it  will  be  best  to  keep  the  patient  in  the  recumbent  posture  with 
the  arm  extended  upon  a  pillow. 

Finally,  whatever  may  be  the  mode  of  dressing,  let  me  repeat  the 
injunction  to  examine  the  arm  frequently.  No  surgeon  can  do  justice 
to  himself,  or  to  his  patient,  who  does  not  look  at  the  arm  at  least 
once  in  twenty-four  hours  during  the  first  ten  or  fourteen  days,  and 
in  some  cases  the  patient  ought  to  be  seen  twice  daily. 

When  the  fracture  is  compound,  it  is  often  quite  impossible  to 
retain  the  forearm  in  the  half-proned  position ;  since,  when  thus 
placed,  and  only  slightly  supported,  as  it  must  necessarily  be,  it 
inevitably  falls  over  upon  its  palmar  surface. 

There  can  be  no  doubt  that  in  such  a  case  we  ought  from  the  first, 
if  it  is  found  practicable,  to  place  it  upon  its  back,  in  a  position  of 
complete,  or  nearly  complete  supination.  For  this  purpose,  a  single 
broad  splint,  carefully  cushioned  and  covered  with  oiled  cloth,  is  the 
most  suitable.     Upon  this  the  forearm  is  to  be  laid  and  secured  gently 


FEACTUEES  OF  THE  CAEPAL  BONES.  325 

with  a  few  turns  of  the  roller.  If  the  patient  is  able  to  do  so,  and 
wishes  to  walk  about,  the  board  may  be  suspended  to  the  neck,  as 
recommended  by  M.  Mayor. 

I  have  said  that  we  ought  in  case  of  a  compound  fracture  to  lay  the 
forearm  upon  its  back  if  practicable.  I  am  sure,  however,  that  the 
surgeon  will  find  very  many  patients  who  cannot  endure  this  position, 
and  he  may  be  compelled  therefore  to  lay  the  limb  upon  its  palmar 
surface,  or  to  leave  it  to  assume  any  other  position  in  which  it  may  be 
the  most  at  ease. 


CHAPTER    XXIV. 

FRACTURES  OF  THE  CARPAL  BONES. 

The  few  cases  of  fracture  of  the  carpal  bones  which  have  come 
under  my  observation  were,  without  exception,  compound  and  com- 
plicated, and  have  resulted  in  the  complete  loss  of  the  hand,  or  in 
some  less  serious,  but  never  inconsiderable  mutilation  or  maiming. 

In  no  case  has  a  treatment  been  adopted  which  might  be  regarded 
as  having  reference  to  the  fracture,  or  the  purpose  of  which  was  to 
insure  apposition  and  union  of  the  fragments. 

It  may  be  proper  to  assume,  in  a  matter  so  easily  comprehended, 
what  actual  and  recorded  experience  has  not  proven,  namely,  that 
simple  fractures  of  these  bones  will  demand  very  little  surgical  inter- 
ference, and  that  they  will  unite  generally  .without  much  displacement, 
and  without  any  considerable  maiming.  It  is,  indeed,  quite  probable 
that  some  degree  of  anchylosis  between  their  adjacent  surfaces  will 
occur,  yet  even  in  the  normal  condition  they  enjoy  so  little  motion  as 
to  render  it  doubtful  whether  its  complete  loss  would  be  very  sensibly 
felt. 

In  cases  of  comminuted,  compound,  and  otherwise  complicated  frac- 
tures of  the  carpal  bones,  which  accidents  are  sufficiently  common, 
the  surgeon  has  only,  I  conceive,  to  follow  carefully  those  genei^al  or 
special  indications  which  may  happen  to  be  present,  the  precise 
character  of  which  it  would  be  difficult  to  anticipate,  and  for  the  treat- 
ment of  which  it  would  be  unsafe  to  attempt  in  a  written  treatise  to 
provide. 


326       FEACTURES  OF  THE  METACARPAL  BONES. 


CHAPTER    XXV. 

FEACTURES    OF   THE   METACARPAL   BONES. 

Causes. — These  bones,  also,  are  generally  broken  bj  direct  blows; 
and  in  that  case  the  injury  is  often  of  such  a  character  as  to  demand 
amputation,  and  does  not  therefore  belong  to  that  class  of  accidents 
of  which  it  is  the  purpose  of  this  volume  to  treat.  Not  an  incon- 
siderable number,  however,  are  the  results  of  indirect  blows,  and  es- 
pecially of  blows  upon  the  knuckles  received  in  pugilistic  encounters. 
Thus,  in  a  record  of  ten  fractures,  I  find  this  cause  assigned  in  three ; 
in  one  other  instance  it  was  occasioned  by  falling  upon  the  clenched 
fist,  and  in  one  by  striking  a  board;  so  that  the  fracture  has  resulted 
from  a  blow  upon  the  ends  of  the  bones  in  five  of  the  ten  examples. 

Dorsey,  in  his  Elements  of  Surgery,  mentions  also  that  he  has 
known  the  metacarpal  bones  to  be  fractured  in  pugilistic  contests. 

Point  of  Fracture  ;  Direction  of  Displacement ;  Symptoms. — Once  the 
fracture  has  occurred  in  the  metacarpal  bone  of  the  thumb ;  four 
times  in  the  metacarpal  bone  of  the  index  finger;  three  times  in  the 
ring,  finger,  and  twice  in  the  metacarpal  bone  of  the  little  finger. 
Two  of  those  belonging  to  the  ring  finger,  and  the  two  occurring  in 
the  little  finger,  were  produced  by  blows  with  the  clenched  fist,  and  in 
each  instance  the  fracture  was  in  the  lower  or  distal  third  of  the  bone. 
One  of  the  fractures  of  the  metacarpal  bone  of  the  index  finger  was 
produced  also  in  the  same  way ;  but  the  fracture  was  near  the  middle 
of  the  bone.  Of  the  whole  number,  six  were  broken  through  the 
lower  third,  two  through  the  middle,  and  two  through  the  upper  third. 

In  every  instance  where  the  bone  is  known  to  have  been  broken  by 
a  blow  upon  the  knuckles,  the  lower  end  of  the  lower  fragment  was 
thrown  toward  the  palm,  and  the  bone  was  salient  backwards  at  the 
point  of  fracture. 

In  the  following  case  the  bone  was  probably  separated  at  the  epi- 
physis. 

Thomas  Eose,  set.  8,  fell  down  a  flight  of  steps,  Sept.  11,  1855, 
breaking  the  metacarpal  bone  of  the  index  finger  of  the  right  hand 
near  its  lower  extremity,  and  apparently  at  the  junction  of  the  epi- 
physis with  the  diaphysis. 

I  saw  the  lad  about  sixteen  hours  after  the  accident.  The  lower 
fragment,  projecting  abruptly  into  the  palm  of  the  hand,  could  be 
easily  replaced,  or  with  only  moderate  eflbrt,  yet  immediately  when 
the  support  was  removed  it  would  become  displaced.  There  was  no 
crepitus. 

It   was  dressed  very   carefully  with  a   splint  and  compress;  but 


FEACTUEES    OF    THE    METACAEPAL    BOISTES.  327 

notwithstanding  our  continued  efforts  to  keep  the  fragments  in  place, 
the  epiphysis  united  considerably  depressed  toward  the  palm. 

In  one  instance,  also,  I  think  the  bone  was  rather  bent,  or  partially 
fractured,  than  broken  completely.  This  was  the  case  of  fracture  of 
the  metacarpal  bone  of  the  ring  finger,  produced  in  a  gymnasium  by 
striking  with  the  clenched  fist  against  a  board,  and  to  which  I  have 
already  alluded.  I  did  not  see  the  young  man  until  four  weeks  after 
the  accident,  when  I  found  the  lower  end  of  the  bone  depressed  toward 
the  palm  and  the  angle  made  at  the  point  of  fracture  was  rather 
rounded  and  quite  smooth ;  it  was  also  tender  at  this  point,  but  the 
bone  was  firm  and  unyielding.  Four  years  after  I  was  permitted  to 
examine  it  again,  and  I  found  the  same  slight  deformity  still  con- 
tinuing. 

A  partial  explanation  of  the  fact  that  the  joint  end  of  the  lower  frag- 
ment is  generally  displaced  toward  the  palm,  may  be  found  in  the  natural 
curve  of  these  bones,  which  is  such  that  when  the  fracture  has  been 
produced  by  a  counter-stroke,  the  distal  end  would  almost  necessarily 
be  driven  in  this  direction ;  and  a  further  explanation  has  been  sug- 
gested by  Mr.  B.  Cooper,  namely,  the  action  of  the  interossei. 

Results. — Generally,  when  the  fracture  is  simple,  and  the  displace- 
ment is  not  considerable,  the  nature  of  the  accident  is  overlooked,  and 
some  deformity  must  inevitably  ensue.  In  a  majority  of  the  cases 
which  have  come  under  my  observation  this  has  been  the  fact,  and 
the  bone  has  remained  slightly  bent  at  the  seat  of  fracture,  but  with- 
out affecting  in  any  degree  the  value  of  the  hand. 

The  following  example  has  furnished  the  most  serious  result  of 
any  case  of  simple  fracture  of  these  bones  which  has  come  under  my 
notice. 

Louis  Mooney,  aet.  25,  struck  a  man  with  his  clenched  fist,  Nov. 
4,  1856,  breaking  the  metacarpal  bone  of  the  index  finger  of  the  right 
hand,  near  its  middle.  He  was  under  the  care  of  a  surgeon  residing 
in  this  city.     Great  swelling  and  suppuration  followed  the  injury. 

February  21,  1857,  nearly  four  months  after  the  injury  was  re- 
ceived, he  consulted  me.  There  existed  at  this  time  a  complete  anchy- 
losis at  the  wrist-joint,  and  partial  anchylosis  in  the  fingers.  The  hand 
was  deflected  forcibly  to  the  radial  side.  At  the  point  of  fracture  the 
fragments  were  salient  backwards  and  quite  prominent,  but  firmly 
united. 

Even  when  the  existence  of  the  fracture  is  recognized,  it  is  not 
always  easy  to  retain  the  fragments  in  place,  as  the  case  of  epiphyseal 
separation  already  mentioned,  and  the  following  case,  will  illustrate. 

Miss  E.,  of  Erie  Co.,  K  Y.,  get.  18,  fell,  Aug.  7,  1858,  striking  upon 
her  right  hand  with  her  fingers  forcibly  bent  into  the  palm  of  the 
hand.  On  the  following  day  she  consulted  me  at  my  office,  and  I 
found  the  metacarpal  bone  of  the  ring  finger  broken  about  three- 
quarters  of  an  inch  from  its  lower  end,  and  the  distal  extremity  of 
the  fragment  depressed  toward  the  palm.  A  feeble  crepitus,  with 
distinct  motion,  completed  the  diagnosis.  The  young  lady  was  very 
anxious  to  have  a  perfect  hand,  and  I  was  determined  if  possible  to 
accomplish  it.     Finding  that  the  lower  fragmeut  was  constantly  dis- 


328       FEACTUEES  OF  THE  METACAEPAL  BON-ES. 

posed  to  fa]]  toward  the  palm,  I  constructed  a  gutta-percha  splint  for 
the  hand  and  fingers,  and  after  placing  a  pad  directly  underneath 
this  fragment,  I  secured  it  firmly  with  a  roller.  From  this  time  until 
the  end  of  four  weeks  she  remained  under  my  care,  visiting  me  as 
often  as  once  or  twice  a  week ;  and  at  each  dressing  I  found  the  lower 
fragment  slightly  displaced  in  the  same  direction  as  at  first,  nor  was  I 
able  ever  to  make  it  resume  completely  its  position. 

Ordinarily,  however,  no  such  difficulty  is  experienced,  and  the 
bone,  supported  by  such  simple  means  as  we  shall  presently  direct 
unites  quickly  and  without  deformity.  ' 

An  engineer,  residing  in  this  city,  was  struck  by  a  piece  of  iron  in 
such  a  way  as  to  break  his  right  forearm  and  the  second  metacarpal 
bone  of  the  same  hand.  The  fracture  of  the  metacarpal  bone  was 
compound  and  about  three-quarters  of  an  inch  from  its  proximal  ex- 
tremity. When  he  called  upon  me,  which  was  immediately  after  the 
injury  was  received,  I  found  the  proximal  fragment  projecting  directly 
backwards,  its  sharp  point  rising  above  the  skin;  into  which  position 
It  was  evidently  drawn  by  the  action  of  the  extensor  carpi  radialis 
longior  muscle.  By  pressure  alone  it  could  be  replaced,  but  it  was 
much  more  easily  reduced  when  the  hand  was  forcibly  carried  back- 
wards on  the  forearm.  I  therefore  secured  the  hand  in  this  position 
with  appropriate  splints,  and  it  was  maintained  in  this  posture  durino- 
mpst  of  the  subsequent  treatment.  Union  finally  took  place,  but  nol 
without  some  backward  displacement.  Four  months  after  the  accident 
occurred,  on  the  31st  of  Dec.  ]  868,  I  examined  the  hand,  and  found  the 
skin  ,healed  over  completely,  the  end  of  the  fragment  having  become 
rounded  and  smooth  so  as  not  to  give  him  any  degree  of  annoyance. 
His  wrist  was  as  flexible  and  as  strong  as  before.  No  doubt  the  pro- 
jection of  the  fragment  might  have  been  prevented  entirely  by  cutting 
at  the  point  of  its  attachment  the  tendon  of  the  extensor  muscle,  bu^t 
this  would  have  sensibly  weakened  the  wrist-joint,  and  I  preferred  the 
alternative  of  a  projection  of  the  fragment. 

Treatment.— Wii\i  moderate  extension  made  upon  the  finger  cor- 
responding to  the  broken  bone,  while  the  fragments  are  forced  home 
by  firm  pressure,  the  bone  may  generally  be  brought  at  once  into  line, 
and  we  may  now  proceed  to  adapt  a  gutta-percha,  felt,  or  thick  paste- 
board splint,  to  either  the  whole  surface  of  the  back  or  palm  of  the 
hand  and  fingers,  while  they  are  held  in  a  position  of  easv  flexion. 
It  is  not  very  material  to  which  of  these  surfaces  the  splint  is  applied  ; 
or  rather,  I  may  say,  it  ought  to  be  applied  to  the  one  or  the  other 
according  as  circumstances  seem  to  indicate.  It  should  be  well  pad- 
ded, and  especially  at  certain  points,  in  order  to  the  more  effectual 
support  of  the  fragments.  It  is  then  to  be  secured  in  place  with 
several  turns  of  a  roller.  When  either  of  the  metacarpal  bones,  ex- 
cept those  of  the  great  or  ring  finger,  is  broken,  the  splint  must  be 
wide  enough  to  secure  the  sides  of  the  hand  against  the  pressure  of  the 
roller. 

Thus  dressed,  the  hand  may  be  laid  in  a  sling  beside  the  chest,  or 
while  sitting  it  may  rest  upon  a  table. 

The  apparel  must  be  examined  daily,  and  readjusted  as  often  as  it 


FRACTURES    OF    THE    FINGERS.  329 

shall  become  disarranged,  or  as  a  doubt  shall  arise  as  to  the  condition 
of  the  parts. 

When  the  fracture  is  followed  by  much  inflammation,  or  occurs 
near,  and  especially  if  it  actually  involves  a  joint,  the  same  precau- 
tions must  be  adopted  to  prevent  anchylosis  as  in  the  case  of  similar 
fractures  in  other  bones. 


CHAPTER    XXVI. 

FRACTUEES  OF  THE  FINGERS. 

Causes. — I  do  not  remember  to  have  seen  a  fracture  of  one  of  the 
phalanges  produced  by  a  counter-stroke ;  I  am  aware,  however,  that 
they  are  occasionally  produced  in  this  way,  as  by  falling  upon  the 
ends  of  the  fingers,  and  especially  by  the  stroke  of  a  ball  in  the  game 
of  base. 

The  fact,  however,  that  they  are  generally  the  consequence  of  a 
direct  blow,  and  that  the  finger  bones  are  small  and  only  protected  by 
a  thin  covering  of  skin  and  tendons,  renders  them  peculiarly  liable  to 
comminution  and  to  other  serious  complications.  Thus,  in  a  record 
of  thirty  fractures,  only  eighteen  were  sufficiently  simple  to  warrant 
an  attempt  to  save  them  ;  and  only  five  are  recorded  as  simple  frac- 
tures without  complications. 

The  majority  of  those  fingers  which  were  saved  were  broken 
through  the  first  phalanx. 

Twice  the  fracture  has  seemed  to  be  a  mere  separation  of  the  epi- 
physis. The  first  was  in  the  person  of  a  boy  twelve  years  old,  the 
separation  having  taken  place,  in  consequence  of  a  crushing  injury, 
at  the  distal  end  of  the  first  phalanx  of  the  second  or  large  finger.  A 
peculiar  crepitus,  with  motion,  was  easily  detected,  but  there  was  no 
displacement.  A  splint  was  applied  and  union  occurred  in  a  few 
days,  and  without  any  deformity. 

The  second  was  in  a  lad  four  years  old,  who  was  admitted  to  the 
Hospital  of  the  Sisters  of  Charity,  Dec.  24,  1849,  with  a  simple  frac- 
ture of  the  first  phalanx  of  the  ring  finger  of  the  left  hand  ;  the  frac- 
ture being  at  the  proximal  end  of  the  bone,  and  at  the  junction  of  the 
epiphysis  with  the  shaft. 

The  finger  was  so  much  swollen  at  first,  that  no  dressings  were 
applied  until  the  fifth  day,  at  which  time  a  gutta-percha  splmt  was 
moulded  to  it  carefully.     It  resulted  in  a  perfect  cure. 

I  have  never  seen  the  fragments  much  overlapped,  except  in  one 
instance.  Frequently  there  has  been  no  perceptible  displacement 
whatever ;  but  generally  there  will  be  found  a  slight  displacement 
in  the  direction  of  the  diameter  of  the  bone. 


330  FEACTUEES    OF    THE    FINGEES. 

The  case  to  which  I  refer  as  presenting  an  extraordinary  overlapping, 
was  that  of  an  Irish  laboring  woman,  aged  about  thirty-five  years, 
who,  having  fallen  down  a  flight  of  steps,  broke  the  first  phalanx  of 
the  thumb,  below  its  middle.  Dr.  Congar,  of  this  city,  was  first  called 
on  the  day  following  the  accident,  but  was  unable  to  reduce  the  frac- 
ture, and  on  the  same  day  invited  me  to  see  the  patient  with  him. 
The  distal  fragment  was  displaced  backwards,  overlapping  the  proxi- 
mal fragment  a  little  more  than  one-quarter  of  an  inch.  We  made 
repeated  efforts,  by  pulling  upon  the  thumb  with  a  sliding  noose,  and 
with  all  the  strength  of  our  four  hands,  but  to  no  purpose.  The  frag- 
ments could  not  be  reduced  for  one  moment ;  and  we  left  the  patient 
as  we  had  found  her,  only  somewhat  the  worse  for  our  violent  and 
repeated  extensions  and  manipulations.  The  finger  was  already  con- 
siderably swollen  when  we  began  our  efforts,  and  we  cannot  therefore 
say  what  might  have  been  accomplished  at  an  earlier  moment,  but  I 
confess  that  our  defeat  was  unexpected,  and  does  not  seem  to  me  to  be 
satisfactorily  explained. 

Results. — At  least  ten  have  left  no  appreciable  lameness  or  deform- 
ity, and  possibly  several  more.  It  is  therefore  probably  true  that 
these  consequences  may  be  avoided  with  proper  care  in  one-half  of 
the  examples  in  which  we  attempt  to  save  the  finger ;  and  perhaps  it 
will  occasion  surprise  that  a  perfect  result  may  not  be  claimed  in  a 
larger  proportion ;  but  when  we  consider  how  frequently  the  accident 
is  compound,  and  that  even  when  it  is  not,  the  blow  having  generally 
been  received  directly  upon  the  point  of  fracture,  how  promptly 
swelling  ensues,  it  will  be  easily  understood  that  it  will  be  often  found 
difficult  to  determine  whether  the  bone  is  exactly  in  line  or  not,  or  to 
maintain  it  in  this  position  after  absolute  coaptation  has  been  once 
secured. 

I  have  seen  the  finger  in  two  or  three  cases  deviate  laterally,  or 
become  permanently  deflected  to  one  side  or  the  other ;  and  once  I 
have  found  it  united,  but  rotated  on  its  own  axis.  This  latter  case  is 
not  without  instruction. 

A  girl,  set.  6,  had  her  little  finger  caught  by  a  door  violently  shut, 
breaking  one  of  the  phalanges,  and  nearly  severing  the  finger.  I 
closed  the  wound  and  dressed  the  finger  with  a  moulded  pasteboard 
splint.  My  dressings  were  repeated  often,  and  applied  carefully;  nor 
did  I  detect  the  rotation  which  the  lower  fragment  had  made  upon  its 
own  axis  until  the  union  was  consummated.  I  then  found  the  ex- 
tremity of  the  finger  turned  so  that  its  palmar  surface  presented 
diagonally  toward  the  ring  finger. 

If  the  surgeon  believes  that  this  ought  to  have  been  prevented,  and 
that  the  result  evinces  a  lack  of  skill  or  of  care,  its  record  may  still 
serve  one  of  the  purposes  for  which  it  was  designed,  and  secure  to  the 
patient  sometimes  hereafter  more  faithful  and  assiduous  attention. 

Treatment. — Boyer,  and  after  him  Bransby  Cooper,  have  taught  that 
when  the  extreme  phalanx  is  broken,  from  the  small  size  of  the  bone, 
and  from  its  having  attached  to  it  the  nail  and  its  matrix,  it  is  better, 
in  all  cases,  to  amputate  at  once,  as  the  process  of  reparation  is  in 
such  case  extremely  slow  and  uncertain. 


FRACTUEES    OF    THE    FIXGERS.  331 

Whether  in  anv  of  the  cases  treated  bj  myself,  or  which  have  been 
seen  bv  me,  the  fracture  involved  the  last  phalanx,  I  am  not  now  able 
to  say,  but  my  impression  is  that  such  cases  have  come  under  my 
notice  which  have  been  successfully  treated,  and  I  cannot  but  regard 
the  rule  established  by  these  gentlemen  as  much  too  stringent.  Ex- 
amples must,  no  doubt,  sometimes  occur,  in  which  the  fracture  is  so 
simple  in  its  character  as  to  render  prompt  reunion  pretty  certain ; 
and  even  though  the  restoration  should  prove  tedious,  this  ought 
scarcely  to  be  regarded  as  a  sufficient  justification  for  so  serious  a 
mutilation  as  these  surgeons  propose,  since  the  loss  of  even  an  extreme 
phalanx  is  not  only  a  deformity,  but  must  prove  in  many  occupations 
a  troublesome  maiming. 

The  rule  ought  still  to  be  held  inviolate,  which  surgeons  have  so 
often  repeated  in  reference  to  injuries  inflicted  upon  the  hand  and 
fingers,  namely,  that  we  should  save  always  as  much  as  possible. 

It  is  remarkable,  too,  how  much  nature,  assisted  by  art,  can  do 
toward  the  accomplishment  of  this  purpose.  If  the  bone  of  a  finger 
is  not  only  severed  completely,  but  also  all  of  its  soft  coverings,  save 
only  a  narrow  band  of  integument,  are  torn  asunder,  a  chance  remains 
for  its  restoration.  And  it  is  especially  interesting  to  observe  what 
recuperative  powers  are  possessed  by  the  articular  surfaces  of  these 
smaller  joints,  so  that  although  they  may  be  broken  into,  or  sawn 
through,  or  comminuted,  and  although  small  fragments  be  entirely 
removed,  a  complete  restoration  of  their  functions  is  sometimes  per- 
mitted. I  have  seen  and  -reported  some  such  examples.  It  is  true, 
however,  that  such  fortunate  results  are  rare,  and  they  are  rather  to  be 
hoped  for  than  anticipated. 

Since,  in  the  case  of  these  delicate  bones,  the  slightest  deviation 
from  the  natural  form  or  position  determines  in  the  end  an  ugly  de- 
formity, it  becomes  exceedingly  necessary,  especially  with  females, 
that  we  should  open  and  examine  the  fingers  carefully  from  day  to 
day,  so  that,  as  the  swelling  subsides,  we  may  discover  and  correct 
any  displacement  which  may  happen  to  exist. 

As  a  splint,  I  have  found  nothing  so  convenient  as  gutta  percha,  or 
felt,  moulded  accurately  to  either  the  dorsal  or  palmar  aspect  of  the 
finger;  and  the  form  of  which  I  have  found  it  generally  necessary  to 
change  slightly  every  third  or  fourth  day,  until  consolidation  is  nearly, 
or  quite  completed. 

If  the  fracture  is  near,  or  extends  into  a  joint,  the  finger  ought  to 
be  a  little  flexed  so  as  to  place  it  in  the  most  useful  position  in  the 
event  that  anchylosis  should  occur  ;  and  as  early  as  the  end  of  the 
second  week  the  joint  surfaces  should  be  slightly  moved  upon  each 
other  in  order  to  the  prevention  of  fibrous  or  bony  adhesions.  Nor  is 
there  much  danger  of  preventing  the  union  of  the  bone  by  moving 
the  joints  at  this  early  day.  Union  occurs  between  these  fragments 
very  speedih',  and  I  have  never  met  with  a  case  of  non-union  of  the 
phalanges,  nor  do  I  remember  to  have  seen  a  case  reported. 

It  is  the  lateral  inclination  of  the  distal  end  of  the  finger  which, 
according  to  my  experience,  it  will  be  found  most  difficult  to  obviate, 
and  which  may,  perhaps,  in  some  cases  be  most  successfully  combated 


332  FRACTUEES    OF    THE    PELVIS. 

by  laying  the  two  adjoining  sound  fingers  against  the  broken  finger, 
and  then  applying  a  moulded  splint  to  the  palmar  surface  of  the  whole. 
In  other  cases  it  will  be  more  convenient  to  apply  the  splint  only  to 
the  broken  finger. 

Eotation  of  the  lower  fragment  on  its  own  axis  is  especially  to  be 
guarded  against,  as  the  deformity  which  it  occasions  is  more  unseemly, 
and  the  impairment  of  utility  more  decided,  than  that  occasioned  by 
a  lateral  deviation. 

It  may  be  well  also  to  remind  the  surgeon  of  the  convenience  of 
extending  the  splint  beyond  the  end  of  the  last  phalanx,  and  moulding 
it  to  this  extremity,  in  order  that  the  finger  may  be  protected  against 
injuries,  and  that  when,  from  time  to  time,  the  splint  is  removed,  it 
may  be  reapplied  with  accuracy. 

In  all  cases  the  splint  should  be  lined  with  two  or  three  folds  of 
cotton  cloth,  or  soft  flannel,  or  patent  lint,  and  secured  in  place  with 
narrow  and  neatly  cut  cotton  rollers.  Bandages  of  this  width  should 
never  be  torn,  but  carefully  cut  with  scissors. 


CHAPTER    XXVII. 

FRACTURES   OF   THE   PELVIS,   AND   TRAUMATIC 
SEPARATIONS   OF  ITS   SYMPHYSES. 

§  1.   PUBES. 

Lente,  in  bis  reports  from  the  New  York  Hospital,  mentions  the 
case  of  a  young  man,  set.  18,  who  was  crushed  between  a  couple  of 
cars,  in  consequence  of  which  he  died  two  days  after.  The  autopsy 
disclosed  a  separation  at  the  symphysis  pubis,  unaccompanied  with 
any  other  fracture.  The  right  side  was  displaced  backwards  about 
half  an  inch,  so  that  the  fingers  could  be  passed  between  the  bones. 
There  was  also  a  wound  in  the  top  of  the  bladder  large  enough  to 
admit  the  thumb.'  Similar  accidents  have  been  several  times  met  with 
by  surgeons.  Hall  reports  a  case  in  the  Provincial  Medical  and  Surgi- 
cal Journal^  May  1,  1844,  in  which  the  pubes  thus  separated,  was 
actually  thrust  into  the  bladder;  but  in  this  example  the  ilium  was 
broken  also.  I  need  scarcely  add  that  this  patient  died  f  but  Sir 
Astley  Cooper  has  furnished  us  with  an  example  of  a  simple  fracture 
or  traumatic  separation  at  the  symphysis,  from  which  the  patient  after 
a  long  time  almost  completely  recovered.  The  following  is  Sir  Astley 's 
account  of  the  case : — 

'  Lente,  New  York  Journ.  Med.,  2d  ser.,  voL  iv.  p.  286. 
^  Hall,  Amer.  Journ.  Aied.  Sci.,  vol.  xxxiv.  p.  248. 


puBES.  333 

"  Case  79.  Eichard  White,  set.  22,  was  admitted  into  Guy's  Hospital 
on  the  30th  of  July,  1832,  having  sustained  a  severe  injury  in  conse- 
quence of  a  large  quantity  of  gravel  having  fallen  upon  his  back  while 
in  the  act  of  stooping.  It  knocked  him  down  ;  and  on  rising,  which 
he  did  with  considerable  difficulty,  he  attempted  to  walk ;  this  pro- 
duced violent  pain  in  the  region  of  the  bladder,  extending  upwards 
in  the  course  of  the  ureters  to  the  kidneys.  Upon  inquiry,  he  stated 
that  the  urine  he  had  voided  since  the  accident  was  bloody  and  passed 
with  difficulty. 

"  On  examination,  a  fissure  was  found  at  the  symphysis  pubis,  pro- 
ducing a  separation  of  about  two  fingers'  breadth.  On  pressure  being 
made  upon  anv  part  of  the  ilium,  he  complained  of  increased  pain  in 
the  region  of  the  pubes,  and  of  numbness  down  the  left  thigh. 

"A  catheter  was  immediately  passed,  and  the  urine  which  was 
drawn  ofi"  was  clear  and  healthy.  Leeches  were  applied  over  the  pubes, 
and  a  broad  belt  was  firmly  buckled  around  the  pelvis,  sufficiently 
tight  to  bring  the  separated  pubes  nearly  in  contact,  and  the  patient 
ordered  to  be  kept  perfectly  quiet  in  the  recumbent  posture,  on  low 
diet.  The  leech-bites  ulcerated,  and  some  slight  degree  of  fever  re- 
sulted, which,  however,  readily  yielded  to  the  usual  treatment. 

"He  remained  in  the  hospital  for  three  months  w^ithout  any  check 
to  the  progress  of  his  cure;  the  length  of  time  it  required  being  ac- 
counted for  by  the  difficulty  of  reparation  in  an  amphiarthrodial  ar- 
ticulation;  and  when  he  left  there  was  some  slight  separation  of  the 
pubes  remaining;  nor  were  the  two  lower  extremities,  or  the  anterior 
and  superior  spinous  processes  of  the  ilia,  perfectly  symmetrical, 
although  he  could  walk  very  well."^ 

Malgaigne  has  collected  four  cases  of  simple  separations  at  the  sym- 
physis pubis  occasioned  by  external  violence,  and  in  three  of  the  four 
cases,  it  was  occasioned  by  pressing  out  the  thighs  with  great  force; 
the  separation  being  directly  due,  therefore,  to  muscular  action. 

Two  of  these  patients  succumbed  to  the  accidents.  The  same  author 
has  brought  together,  also,  seventeen  cases  of  separations  of  this  sym- 
physis occurring  in  childbirth,  of  which  only  seven  survived. 

It  is  much  more  common,  however,  to  find  the  pubes  broken  through 
its  horizontal  or  ascending  ramus;  and  Clark,  of  the  Massachusetts 
General  Hospital,  has  described  a  case  of  simultaneous  fracture  of  the 
pubes  and  ischium  in  three  places.  The  man,  ast.  29,  had  been  caught 
between  two  heavy  timbers,  and  on  the  following  day,  ]\Iay  7,  1852, 
he  was  brought  to  the  hospital. 

No  crepitus  could  be  detected,  but  he  was  unable  to  lie  upon  the 
right  side,  and  the  right  limb  was  nearly  paralyzed.  It  was  evident 
that  the  bladder  or  urethra  had  been  ruptured,  and  on  the  third  day 
Dr.  Clark  opened  the  bladder  through  the  perineum,  evacuating  a 
large  amount  of  blood  and  urine,  and  affording  to  the  patient  very 
sensible  relief,  on  the  first  of  June,  however,  he  died,  having  sur- 
vived the  accident  twenty  five  days. 

'  Sir  Astley  Cooper,  Frac.  and  Disloc,  Amer.  ed.,  p.  144. 


334 


FEACTUEES    OF    THE    PELVIS. 


Fig.  99. 


Clark's  case  of  fracture  of  the  pelvis. 


The  autopsy  disclosed  several  fractures,  all  of  which  belonged  to 
the  right  os  innominatum.     First,  a  fracture  of  the  pubes,  near  the 

symphysis;  second,  a  fracture  near 
the  junction  of  the  pubes  and  ilium; 
third,  a  fracture  through  the  ramus 
of  the  ischium  anterior  to  the  tubero- 
sity.' 

Sir  Astley  mentions  a  case  (Case 
83)  of  fracture  of  the  "  ramus  of  the 
pubes,"  unaccompanied  with  injury 
to  the  bladder  or  urethra,  which  re- 
sulted in  a  complete  recovery;  and 
in  another  case  (Case  84)  the  patient 
recovered  in  eight  weeks,  and  was 
able  to  walk  nearly  as  well  as  before : 
but  he  soon  after  died  of  disease 
of  the  chest.  The  os  pubis  was 
found,  at  the  autopsy,  to  have  been 
broken  in  three  places;  there  was 
also  a  fracture  extending  in  two 
directions  through  the  acetabulum, 
with  an  extensive  comminuted  frac- 
ture of  the  ilium  accompanied  with  great  displacement. 

Maret  has  even  found  it  necessary  after  a  fracture  to  remove  nearly 
the  whole  of  the  body  of  the  pubes  by  incision,  in  a  girl  of  18  years, 
and  who  not  only  recovered  completely,  but  having  subsequently 
married,  she  gave  birth  to  two  children  in  easy  and  natural  labors.^ 

Cappelletti  relates  that  a  man,  set.  54,  jumped  from  a  carriage,  the 
horses  having  run  away,  and  alighted  with  his  feet  to  the  ground,  but 
with  one  limb  in  the  greatest  possible  degree  of  abduction.  A  surgeon, 
who  saw  him  immediately,  found  an  enormous  swelling  at  the  superior 
part  of  the  thigh,  accompanied  with  very  acute  pain.  When  seen  by 
Cappelletti,  at  Trieste,  six  months  after,  there  still  remained  a  slight 
swelling  near  the  ramus  of  the  ischium  and  pubes,  under  which  a 
careful  examination  detected  a  fragment  of  bone  two  and  a  half  inches 
long  and  of  the  "  size  of  the  finger."  The  patient  was  able  to  walk, 
but  not  without  pain  and  limping.  Cappelletti  soon  began  to  suspect 
that  this  fragment  of  bone  consisted  of  a  part  of  the  ramus  of  the 
ischium  and  pubes  detached  by  muscular  contraction.  On  examining 
it  anteriorly  he  found  this  part  of  the  pelvis  defective,  and  the  loose 
portion  of  bone  had  all  of  the  anatomical  characters  of  the  defective 
part.  He  felt  distinctly  the  circular  projection  indicating  the  point 
where  the  ascending  branch  of  the  ischium  unites  with  the  descending 
branch  of  the  pubes.^ 

Whitaker,  of  Lewiston,  N.  Y.,  saw  the  body  of  the  left  os  pubis 
broken  in  a  female  while  in  the  seventh  month  of  pregnancy.     She 

'  Clark,  Boston  Med.  and  Surg.  Journ.,  vol.  liii.  p.  185. 
^  Maret,  from  Malgaigne,  op.  oit.,  p.  646. 

*  Cappelletti,  Ranking's  Abstract,  No.  viii.  p.  83  ;  from  Giornale  per  servire  al  Pro- 
gressi  della  Patologie  della  Teraputica,  1847. 


ISCHIUM.  335 

had  fallen  down  a  pair  of  stairs,  striking  astride  the  edge  of  an  open, 
upright  barrel.  The  fracture  was  oblique,  and  with  but  little  dis- 
placement, yet  she  complained  of  excruciating  pain  in  the  left  pubic 
region  on  the  least  motion.  The  accident  was  followed  by  no  positive 
attempt  at  miscarriage.^ 

The  danger  in  these  accidents  consists  not  so  much  in  the  fracture, 
as  in  the  injury  done  to  the  bladder,  and  other  pelvic  viscera.  If  the 
bladder  is  opened  into  the  peritoneal  cavity,  death  is  almost  inevit- 
able, and  even  when  the  bladder  or  urethra  has  suffered  laceration 
lower  down  or  at  any  point  above  the  deep  perineal  fascia,  extensive 
urinary  infiltrations,  followed  by  abscesses  and  gangrene,  generally 
expose  these  patients  to  the  most  imminent  hazards. 

The  practice  pursued  at  Guj^'s  Hospital  in  the  case  of  separation  at 
the  symphysis  pubis,  commends  itself  both  by  its  simplicity  and  by 
its  success.  Antiphlogistic  remedies  steadily  pursued,  rest  in  the  re- 
cumbent posture,  the  use  of  the  catheter  when  necessary,  and  in 
certain  cases  the  girding  the  pelvis  with  a  firm  belt  or  band,  are  mea- 
sures which  seem  to  meet  all  of  the  important  indications. 

If  the  fracture  is  accompanied  with  displacement,  it  will  be  proper 
to  attempt  to  restore  the  fragments,  but  except  in  the  case  of  separation 
at  the  symphysis  very  little  aid  can  be  expected  from  a  band  or  any 
similar  means,  in  retaining  them  in  place.  It  will  be  sufiicient,  gene- 
rally, in  such  examples  to  place  the  patient  quietly  upon  his  back,  with 
his  thighs  flexed  upon  his  body,  and  to  treat  the  accident  in  all  other 
respects  as  a  case  of  inflammation. 

If  the  urine  has  become  extravasated  underneath  the  pelvic  fascia, 
no  time  ought  to  be  lost  in  opening  freely  through  the  perineum,  and 
in  extending  the  incisions,  if  necessary,  into  the  urethra  and  bladder. 


§  2.    ISCHITJM. 

When  speaking  of  fractures  of  the  pubes  we  have  already  noticed 
some  examples  of  fractures  of  the  ischium  also ;  indeed,  it  is  seldom 
that  one  of  the  bones  of  the  innominata  is  broken  without  a  coinci- 
dent fracture  of  one  or  both  of  the  others.  The  records  of  surgery 
furnish  several  other  examples,  produced  generally  by  a  fall  upon  the 
tuberosities ;  but  perhaps  the  most  remarkable  instance  is  that  men- 
tioned by  Maret  as  having  occurred  in  a  female  during  labor. 

The  following  summary  of  a  case  of  fracture  of  the  ischium,  reported 
by  Sir  Astley  Cooper,  will  serve  to  illustrate  one  of  the  most  fortunate 
terminations  of  these  accidents  when  accompanied  with  a  rupture  of 
the  urethra : — 

A  young  man  who  was  driving  a  cart,  was  thrown  down  and  a 
wheel  passed  over  him.  On  the  following  morning  he  was  found  to 
have  a  fracture  of  the  left  leg  and  a  contusion  of  the  inner  side  of  the 
left  thigh.  There  was  also  great  swelling  and  ecchymosia  of  the 
scrotum,  with  a  slight  appearance  of  injury  over  the  pubes  and  left 

•  Whittaker,  Amer.  Joum.  Med.  Sci,,  July,  1857,  p.  283. 


836  FEACTURES    OF    THE    PELVIS. 

hypochondriura.  No  fracture  of  the  pelvis  was  at  that  time  discovered. 
The  patient  was  suffering  great  pain,  and  was  cold  and  exhausted. 
Bloody  urine  escaped  from  the  bladder.  On  the  eighth  day  an  abscess 
had  pointed  on  the  left  side  of  the  perineum,  which,  being  opened, 
discharged  a  great  quantity  of  pus  having  the  odor  of  urine ;  extensive 
sloughing  occurred,  and  the  patient  sank  very  low.  On  introducing 
the  finger  into  the  wound,  the  ascending  ramus  of  the  ischium  could 
be  distinctly  felt,  and  the  fracture  traced  in  an  oblique  course,  the 
upper  fragment  being  slightly  displaced  forwards.  When  the  catheter 
was  introduced  into  the  urethra  it  was  found  to  enter  this  wound,  and 
could  be  felt  resting  against  the  naked  bone.  From  this  time  until 
the  twenty-sixth  day,  the  urine  continued  to  escape  freely  through  the 
wound.  Jn  about  six  weeks  more  the  fistulous  opening  had  entirely 
closed,  and  after  several  months  his  recovery  was  complete.' 

The  signs  of  this  accident  are  generally  even  more  obscure  than 
those  of  fracture  of  the  pubes,  but  in  a  case  of  doubt  the  bones  ought 
not  only  to  be  carefully  examined  from  without,  but  the  finger  should 
be  introduced  freely  into  the  rectum  and  the  anterior  surface  explored; 
or  the  tuber  ischii  may  be  grasped  between  the  thumb  and  finger  and 
moved  laterally  in  order  to  determine  the  existence  of  motion  or  crepi- 
tus. If  the  patient  is  a  female,  this  exploration  can  be  best  made  through 
the  vagina.  By  flexing  and  extending  the  thigh,  also,  crepitus  may 
sometimes  be  discovered.  The  examination  will  generally  be  made 
whilp  the  patient  lies  upon  his  back,  but  if  turning  is  not  found  too 
painful,  it  will  be  well  to  lay  him  upon  his  face  that  the  tuberosities 
of  the  ischium  may  be  more  plainly  brought  into  view. 

A  considerable  proportion  of  the  fractures  of  both  the  pubes  and 
the  ischium  are  accompanied  with  lesions  of  the  bladder  or  of  the 
urethra,  either  of  which  circumstances  will  render  the  prognosis  very 
unfavorable;  but  in  simple  fractures  recoveries  may  generally  be 
expected,  yet  only  after  a  tedious  confinement. 

It  is  not  usual  except  in  cases  which  must  almost  necessarily  prove 
fatal,  to  find  much  displacement  of  the  fragments;  nor  is  it  probable 
that  by  any  manoeuvres  the  slight  displacements  which  are  found  to 
exist  can  be  entirely  overcome.  Instances  may  occur,  however,  in 
which  careful  pressure  from  without,  or  the  introduction  of  a  finger 
"into  the  rectum  or  vagina  may  aid  in  the  restoration. 

The  posture  best  suited  to  these  cases  will  be  indicated  usually  by 
the  sensations  of  the  patient  himself.  Ordinarily  he  will  prefer  to  lie 
upon  his  back  with  his  thighs  flexed  and  supported  by  pillows;  and 
his  hips  slightly  elevated  by  a  firm  cushion  laid  under  the  upper  part 
of  the  sacrum.  His  knees  ought  also  to  be  gently  bound  together; 
but  if  the  patient  finds  this  position  painful  or  excessively  irksome,  as 
sometimes  he  will,  he  may  be  permitted  to  occupy  any  position  which 
he  finds  most  comfortable. 

'  A,  Cooper,  by  Bransby  Cooper,  Amer.  ed.,  p.  140. 


ILIUM.  337 


§  3.  Ilium. 

Fractures  of  the  ilium,  are  much  more  common  than  fractures  of 
either  the  ischium  or  pubes,  and  they  assume  a  great  variety  of  forms, 
directions,  and  degrees  of  complications. 

In  the  two  following  examples  the  anterior  superior  spinous  process 
alone  was  broken  off: — 

John  Kelly,  £et.  36,  admitted  to  the  Hospital  of  the  Sisters  of  Charity 
Dec.  28,  1852,  having  just  fallen  and  broken  the  anterior  superior 
spinous  process  of  the  ilium.  The  fragment  was  displaced  downwards 
about  one-quarter  of  an  inch.  Motion  and  crepitus  distinct.  Slight 
ecchymosis  over  the  point  of  fracture,  and  other  signs  of  contusion 
about  the  hip.  He  was  intoxicated  at  the  time  of  the  accident,  and 
could  not  tell  how  or  where  he  fell. 

He  was  laid  upon  his  back  in  bed,  with  his  thighs  flexed  upon  his 
body ;  and  in  this  position  we  attempted  to  reduce  the  fragment  and 
retain  it  in  place  with  a  bandage,  but  finding  this  impossible,  we  left 
him  with  only  instructions  to  remain  quietly  in  bed.  In  about  two 
weeks  the  fragment  was  firmly  fixed  in  its  new  position,  and  he  was 
allowed  to  get  up  and  walk  about,  which  he  was  able  to  do  without 
inconvenience. 

July  18,  1853,  Matthias  Morrison  was  caught  under  a  bank  of  falling 
earth,  and  on  the  following  day  Dr.  Mixer,  his  attending  surgeon, 
requested  me  to  see  the  case  with  him.  He  was  unable  to  stand  upon 
his  feet.  There  was  a  lacerated  wound  and  an  extensive  bruise  on 
his  left  hip;  but  the  thigh  was  not  shortened  nor  everted,  and  he  could 
flex  it  slightly  upon  his  body.  Noticing  a  swelling  and  discoloration 
in  the  region  of  the  anterior  superior  spinous  process  of  the  ilium,  I 
pressed  upon  it  and  felt  it  recede  with  a  distinct  crepitus;  the  frag- 
ment, however,  immediately  resumed  its  place  when  the  pressure  was 
removed.  I  was  able  also,  by  a  careful  manipulation,  to  trace  the  line 
of  fracture,  and  to  determine  that  it  included  a  small  portion  of  the 
anterior  extremity  and  wing  of  the  pelvis. 

We  directed  the  patient  to  remain  quietly  upon  his  bed  with  his 
legs  drawn  up.  He  soon  recovered,  but  I  am  unable  to  say  what  is 
the  present  position  of  the  fragment. 

More  frequently,  however,  the  fracture  involves  a  still  larger  por- 
tion of  the  crest,  as  in  the  following  examples : — 

Joseph  Joquoy,  set.  40,  was  caught  by  the  bumpers  between  tv/o 
cars,  Feb.  10,  1854,  breaking  obliquely  the  anterior  superior  portion 
of  the  ilium.  I  saw  him  within  an  hour,  and  found  him  greatly  pros- 
trated ;  the  fragment  of  the  pelvis  broken  off"  was  quite  movable,  and 
crepitus  was  easily  detected.  His  abdomen  was  very  tender  and 
slightly  bloated. 

He  was  laid  upon  his  back  with  his  legs  drawn  up,  and  hot  fomen- 
tations of  hops  and  vinegar  were  directed  to  be  applied  to  his  belly. 
He  took  also  one  grain  of  morphine.  The  broken  ala  did  not  seem 
disposed  to  become  displaced.  With  no  other  treatment,  his  recovery 
.    22 


33S  FEACTUEES    OF    THE    PELVIS. 

was  rapid ;  and  the  bones  seemed  to  have  united  without  displace- 
ment. 

James  Koche,  set.  41,  fell,  March  7,  1854,  from  a  height  of  fourteen 
feet,  breaking  oft"  the  anterior  superior  portion  of  the  right  ala  of  the 
pelvis.  On  the  following  day,  I  found  him  at  the  Hospital  of  the 
Sisters  of  Charity.  The  fragment,  which  was  quite  large,  was  mova- 
ble, and  occasionally  a  crepitus  could  be  detected.  It  was  displaced 
downwards  and  forwards  about  three-quarters  of  an  inch. 

He  was  laid  upon  his  back,  with  his  thighs  and  legs  moderately 
flexed.  At  the  end  of  two  weeks  he  found  himself  able  to  walk  with- 
out much  difficulty,  and  he  immediately  left  the  hospital.  At  this 
time  the  fragment  was  displaced  in  the  same  manner  and  direction  as 
at  first,  but  I  cannot  say  whether  it  had  united  or  not. 

I  have  once  seen  a  fracture  of  the  posterior  superior  spinous  pro- 
cess, and  I  do  not  know  of  any  other  example. 

Miss  B.,  set.  16,  was  thrown  from  her  horse  backwards,  striking  with 
her  back  upon  the  ground.  She  was  at  first  attended  by  Dr.  Coan,  of 
Ovid,  N.  y. ;  and  she  did  not  come  under  my  care  until  two  weeks 
after  the  accident. 

I  found  a  small  fragment  broken  from  the  posterior  superior  spinous 
process  of  the  ilium,  and  displaced  backwards  in  the  direction  of  the 
spine  about  half  an  inch.  It  was  movable,  and  by  pressure  it  could 
be  partially  restored  to  place,  but  it  would  immediately  return  to  its 
abnormal  position  when  the  pressure  was  removed.  The  injured  hip 
was  p'ainful,  and  occasionally  it  felt  numb.  She  had  previously  suf- 
ferred  from  spinal  irritation. 

I  laid  a  compress  behind  the  fragment,  and  secured  it  in  place  with 
a  roller,  enjoining  perfect  rest.  She  recovered  from  her  lameness  in 
a  few  weeks,  but  I  believe  the  fragment  remains  displaced. 

Extensive  comminuted  fractures  of  the  ilium  are  generally  accom- 
panied with  so  much  injury  of  the  pelvic  viscera  as  to  prove  rapidly 
fatal ;  but  the  following  example  will  show  that  this  rule  admits  of 
exceptions. 

June  5,  1854,  Bernard  Duffie,  set.  32,  was  crushed  under  a  very 
heavy  stone  which  fell  upon  his  back.  I  found  the  left  ala  of  the 
pelvis  broken  into  several  fragments,  between  the  different  portions  of 
which  motion  and  crepitus  were  distinct.  The  fractures  were  near  the 
superior  part  of  the  bone,  commencing  about  two  inches  back  of  the 
anterior  superior  spinous  process,  and  extending  backwards  irregularly. 
There  was  a  narrow  wound  communicating  with  the  fracture,  from 
which  I  removed  a  loose  fragment  of  bone.  The  right  leg  was  also 
broken. 

Four  months  after,  he  was  still  confined  to  his  bed,  and  a  fistulous 
opening  continued  opposite  the  point  of  fracture;  there  existed  also  a 
large  and  irregular  mass  of  ossific  matter  or  callus  around  the  frag- 
ments.    He  soon  after  left  the  hospital. 

Dr.  Sargent,  of  the  Massachusetts  General  Hospital,  has  reported  a 
case  in  which  a  man  received  a  compound  fractui-e  of  the  left  ilium, 
and  several  small  fragments  were  removed.     He  was  discharged  iit 


ILIUM.  339 

the  end  of  three  months  with  a  fistulous  opening  still  remaining,  but 
in  other  respects  he  was  quite  well.' 

The  two  following  cases  illustrate  the  more  fatal  injuries  of  this 
character. 

A  man  was  injured  by  a  steam  boiler  explosion  in  this  city  on  the 
11th  of  February,  1857,  and  died  in  about  two  hours.  I  found  the 
anterior  half  of  the  crest  of  the  ilium  broken  ofi",  and  the  fragments 
driven  into  the  belly.  There  was  no  other  serious  injury  which  I 
could  discover. 

John  O'Keaf  was  crushed  under  a  heavy  stone  Oct.  23,  1851,  break- 
ing and  comminuting  the  al«  of  the  pelvis  on  both  sides,  and  wound- 
ing also  the  iliac  vein.  He  was  taken  to  the  Hospital  of  the  Sisters  of 
Charity,  and  died  in  a  few  hours,  partly  from  the  shock  to  bis  system 
and  partly  from  the  hemorrhage. 

Lente,  of  the  New  York  Hospital,  has  reported  a  case  of  dislocation 
of  the  hip,  which  was  accompanied  with  a  fracture  also  of  the  ala  of 
the.  pelvis  upon  the  same  side.  The  dislocation  was  reduced  on  the 
third  day,  and  the  patient  soon  after  died.  The  autopsy  disclosed 
what  had  not  been  suspected  during  life,  namely,  that  the  left  ilium  was 
broken  horizontally  about  through  its  middle,  and  vertically  through 
the  crest ;  and  also  that  there  was  a  fracture  extending  through  the 
sacro-iliac  synchondrosis,  accompanied  with  considerable  comminution 
of  the  articular  surfaces.  It  was  also  found  that  a  portion  of  the  small 
intestine  was  ruptured,  and  probably  by  one  of  the  sharp  fragments 
of  the  broken  pelvis.^ 

It  is  seldom,  I  think,  that  the  fragments  become  much  displaced ; 
such,  at  least,  has  been  my  experience ;  and  I  have  noticed  in  Dr. 
Neill's  cabinet  three  specimens  of  fracture  of  the  crest  of  the  ilium,  all 
of  which  had  united  without  any  appreciable  displacement.  Dr.  Neill 
also  called  my  attention  to  the  fact  that  in  two  of  these  specimens  the 
ensheathing  callus  was  confined  to  the  outer  surface  of  the  bone,  an 
observation  which  this  gentleman  assures  me  he  has  had  frequen*-. 
occasion  to  make  before  where  the  fracture  belonged  to  a  flat  bone. 

The  same  cabinet  contains  a  specimen  of  gunshot  fracture  of  the 
ilium,  the  ala  being  perforated  by  a  smooth,  round  hole,  about  one 
inch  below  the  crest. 

If  any  displacement  exists,  the  upper  or  loose  fragment  is  generally 
carried  slightly  inwards;  occasionally,  however,  it  is  found  displaced 
upwards,  outwards,  or  downwards. 

Treatment. — In  a  large  majority  of  cases  the  fragments,  if  displaced, 
cannot  be  replaced.  Occasionally,  however,  as  where  the  anterior 
superior  spinous  process  is  broken  off  with  only  a  small  portion  of  the 
crest,  the  fragment  may  be  seized  with  the  fingers  and  carried  outwards 
or  upwards,  or  in  whatever  direction  may  be  necessary ;  but  to  retain 
it  in  this  position  is  generally  quite  impossible.  The  bandage  or 
broad  belt  which  we  have  recommended  in  certain  fractures  of  the 
pubes  would  be  in  these  cases  not  only  useless,  but  absolutely  mis- 

1  Sargent,  Boston  Med.  and  Sursc.  .Journ.,  vol.  liii.  p.  121. 

2  Lente,  New  York  Journ.  of  Med.,  Jan.  1851,  p.  29. 


340  FEACTURES    OF    THE    PELVIS. 

chievous,  since  its  effect  must  be  to  press  inwards  the  fragments,  and 
thus  to  create  a  displacement  which  might  not  otherwise  exist. 

The  surgeon  ought  to  determine  bj  a  careful  examination  the  extent 
and  direction  of  the  fracture,  and,  having  done  what  was  in  his  power 
to  replace  the  fragments,  he  should  lay  his  patient  upon  his  back  with 
the  thighs  drawn  up  and  supported.  This  is  the  position  which  will 
generally  be  found  most  comfortable;  but,  as  in  other  fractures  of  the 
pelvis,  it  may  be  well  always  to  try  the  effect  of  other  positions,  and 
especially  to  determine  their  influence  upon  the  fragments,  and  finally 
to  adopt  that  precise  posture  which  accomplishes  the  indications  best. 

If  the  fracture  is  compound,  and  the  fragments  have  penetrated  the 
belly,  the  wound  should  be  enlarged,  and,  as  far  as  possible,  every 
piece  of  bone  should  be  removed ;  but  if  the  fragments  cannot  be 
found,  the  external  opening  should  be  allowed  to  remain  so  as  to  favor 
their  escape  when  suppuration  shall  have  taken  place. 


§  4.  Acetabulum. 

Although,  strictly  speaking,  fractures  of  the  acetabulum  belong 
always  to  one  or  all  of  those  bones  of  the  pelvis  whose  lesions  have 
already  been  described,  yet  the  peculiar  relations  of  this  cavity  to  the 
femur  render  it  necessary  that  they  should  be  considered  as  a  separate 
class  of  accidents. 

Fractures  of  the  acetabulum  divide  themselves  naturally  into  two 
varieties. 

First,  Fractures  of  the  base  of  the  cavity,  with  or  without  displace- 
ment. 

Second,  Fractures  of  the  rim,  with  or  without  displacement. 

In  fractures  of  the  base  of  the  cavity,  not  accompanied  with  dis- 
placement, nothing  but  crepitus  can  be  present  as  a  sign  of  the 
accident;  and  this  will  scarcely  be  sufficient,  in  itself,  to  enable  the 
surgeon  to  distinguish  it  from  a  fracture  of  the  neck  of  the  femur 
within  the  capsule  without  displacement. 

It  is  probable,  therefore,  that  its  existence  will  only  be  determined 
by  dissection.  Nor  is  it  of  much  importance  that  the  diagnosis  should 
be  made  out ;  since  in  either  case  neither  splints  nor  any  other  sur- 
gical appliances  could  be  of  service.  An  injury  so  severe  as  to  frac- 
ture the  acetabulum  will  necessarily  so  much  bruise  the  body,  and 
concuss  the  viscera  of  the  pelvis  as  to  compel  the  patient  to  remain 
quiet  for  a  number  of  days,  and  this  is  all  that  would  be  thought 
necessary  if  the  nature  of  the  accident  was  exactly  determined. 

Dr.  Neill's  cabinet  contains  a  specimen  of  this  kind,  in  which  the 
fracture,  commencing  near  the  centre,  extends  in  three  directions 
across  the  cotyloid  margins ;  and  in  which  perfect  bony  union  has 
occurred  without  displacement. 

M.  Bouvier  related  to  the  Academy  the  case  of  a  man,  set.  71,  who, 
in  consequence  of  a  fall  from  his  bed,  remained  for  three  weeks  unable 
to  walk,  and  never  was  able  afterwards  to  walk  without  crutches.  No 
fracture  could  be  discovered  during  life,  but  after  his  death,  which 


BASE    OF    THE   ACETABULUM.  341 

occurred  some  months  subsequent  to  the  accident,  a  fracture  was  found 
extending  from  the  ilio-pectineal  eminence  to  the  spine  of  the  ischium, 
and  traversing  the  centre  of  the  acetabulum.  The  fragments  were 
not  displaced,  but  remained  slightly  movable.^ 

The  following  case  was  reported  by  Mr.  Earle  to  the  London 
Medico-Chirurgical  Society,  and  will  be  found  in  the  nineteenth  volume 
of  its  Transactions.  It  is  also  referred  to  by  Sir  Astley,  in  his  Treatise 
on  Fractures  and  Dislocations. 

In  the  month  of  October,  1829,  a  man,  £et.  40,  was  admitted  into  St. 
Bartholomew's  Hospital,  with  a  severe  injury  caused  by  having  fallen 
from  a  height  of  thirty-one  feet  and  striking  upon  the  left  side.  The 
left  leg  was  powerless,  and  shortened.  The  foot  was  everted.  Any 
attempt  to  rotate  the  limb  caused  great  pain,  and  was  accompanied 
with  a  sensible  crepitus.  The  left  trochanter  was  very  much  depressed, 
and  when  it  was  pressed  upon  the  patient  complained  of  deep-seated 
pain  in  the  hip-joint. 

He  recovered  in  eight  weeks,  and  was  able  to  walk  nearly  as  well 
as  before ;  but  he  soon  after  died  of  disease  in  the  chest. 

On  dissection,  a  fracture  was  found  extending  in  two  directions 
through  the  acetabulum  ;  there  was  an  extensive  comminuted  fracture 
of  the  ilium,  with  great  displacement,  and  the  os  pubis  was  broken  in 
three  places. 

The  repair  was  very  complete,  and  Mr.  Earle  remarked  how  nature 
had  guarded  against  any  considerable  deposit  of  new  bone  within  the 
articulation,  which  might  have  interfered  with  the  functions  of  the 
joint,  while  there  was  an  abundant  deposit  of  callus  around  the  other 
parts  of  the  fractured  bone. 

Fractures  of  the  base  of  the  acetabulum,  with  displacement  of  the 
femur  into  the  pelvic  cavity,  constitute  a  much  more  formidable,  and 
unfortunately  a  more  common  form  of  accident. 

Like  the  preceding  variety  of  acetabular  fractures,  they  are  produced 
generally  by  falls  upon  the  trochanter  major,  but  the  force  of  the  con- 
cussion has  been  greater. 

Even  here,  it  is  not  often  that  the  diagnosis  has  been  clearly  made 
out  during  life ;  and  indeed,  generally,  the  true  character  of  the  acci- 
dent has  not  even  been  suspected,  the  surgeons  believing  that  they 
had  to  do  with  a  fracture  of  the  neck  of  the  femur,  or  with  a  disloca- 
tion. In  two  examples  (Cases  71  and  72)  mentioned  by  Sir  Astley 
Cooper  as  having  been  presented  at  St.  Thomas's  Hospital,  the  thigh 
was  thought  to  be  dislocated  backwards. 

In  the  following  example,  reported  by  Lendrick,  of  Dublin,  the 
patient  was  supposed  to  have  a  fracture  of  the  neck  of  the  femur : — 

An  old  man,  well  known  as  the  "  W-andering  Piper,"  was  admitted 
into  the  Mercer  Hospital  in  January,  1839,  suffering  under  phthisis 
pulmonalis  and  acute  inflammation  of  the  hip-joint.  Some  years 
before,  he  had  received  a  severe  injury  by  the  upsetting  of  a  coach, 
and  was  under  treatment  several  months  for  what  was  supposed  to  be 

'  Bouvier,  Amer.  Journ.  Med.  Sci.,  vol.  xxiii.  p.  486 ;  from  Bullet,  de  I'Acad.  Roy. 
de  Med.,  August  15,  1838. 


342  FEACTURES    OF    THE    PELVIS. 

a  fracture  of  tlie  neck  of  the  femur.  Since  that  time  he  had  been 
lame,  but  still  able  to  take  a  great  deal  of  exercise  on  foot  both  in 
Great  Britain  and  in  America.  The  acute  disease  of  the  joint  com- 
menced about  two  months  before  his  admission,  and  he  was  at  first 
under  the  care  of  Sir  Philip  Crampton,  who  remarked  that  the  thigh 
was  only  shortened  about  half  an  inch,  and  expressed  his  surprise  at 
this  fact. 

This  man  died  on  the  17th  of  February,  and  the  dissection  showed 
that  there  had  been  no  fracture  of  the  femur,  but  its  head  and  neck 
were  affected  with  "  morbus  coxse  senilis."  The  head  was  also  thrust 
through  a  rent  in  the  acetabulum  into  the  cavity  of  the  pelvis  ;  but 
the  head  had  again  been  covered  by  a  bony  case,  complete,  except  in 
a  small  portion  about  the  size  of  a  shilling  piece,  and  at  this  point  the 
covering  was  ligamentous. 

The  OS  pubis  had  also  been  broken  at  the  same  time,  and  it  had 
united  so  much  overlapped  that  the  space  between  the  inferior  anterior 
spinous  process  and  the  symphysis  pubis  was  shortened  nearly  an 
inch.  A  portion  of  intestine  was  found  protruding  through  an  open- 
ing in  the  pelvis  and  adherent  to  the  bone,  in  which  situation  it  seemed 
to  have  been  caught  by  the  broken  fragments  and  retained.' 

ISiorel-Lavallee,  in  his  thesis  upon  complicated  luxations,  mentions 
a  case  which  had  come  under  his  observation,  and  which  had  been 
treated  as  a  fracture  of  the  neck  of  the  femur.  The  patient  survived 
the  accident  many  years ;  during  a  part  of  which  time  he  suffered  such 
pain 'in  the  hip-joint  as  to  induce  a  belief  that  it  was  itself  diseased. 
At  his  death  he  was  found  to  have  had  a  multiple  fracture  of  the 
bones  of  the  pelvis,  and  the  head  of  the  femur  had  penetrated  more 
than  an  inch  into  the  cavity  of  the  pelvis,  pressing  upon  the  obturator 
nerve  to  such  a  degree  as  to  have,  no  doubt,  caused  the  severe  pain 
from  which  he  had  suffered,  and  which  had  been  ascribed  to  coxalgia.^ 

In  the  two  cases  mentioned  by  Sir  Astley,  as  having  been  received 
into  St.  Thomas's  Hospital,  the  toes  were  turned  in.  In  the  example 
mentioned  by  the  same  author  as  having  been  presented  at  St,  Bar- 
tholomew's Hospital,  the  toes  were  everted ;  the  two  persons  seen  by 
Lendrick  and  Morel-Lavallee  were  supposed  before  death  to  have  had 
a  fracture  of  the  neck ;  it  is  probable,  therefore,  that  in  both  of  these 
cases  the  toes  were  also  everted.  While  Moore  has  dissected  a  subject 
whose  pelvis  was  broken  into  many  fragments — the  left  os  innomina- 
tum  was  divided  into  three  portions,  corresponding  to  the  three  bones 
of  which  it  was  composed  in  infancy;  the  head  of  the  femur  had  com- 
pletely penetrated  the  basin — the  limb  was  shortened  two  inches,  and 
in  a  position  of  slight  flexion  and  adduction,  but  neither  rotated  out- 
wards nor  inwards.^ 

There  seems,  therefore,  to  be  no  certain  rule  in  relation  to  the  posi- 
tion of  the  limb ;  but  it  is  found  to  take  the  one  position  or  the  other, 
probably  according  to  the  direction  of  the  force  which  has  inflicted  the 

'  Lendrick,  Amer.  Journ.  Med.  Sci.,  voL  xxiv.  p.  481,  August,  1839 ;  from  London 
Med.  Gazette,  March,  1839. 

^  Morel-Lavallee,  from  Malgaigne,  op.  cit.,  vol.  ii.  p.  881. 
3  Moore,  Med.-Chir.  Trans.,  vol.  xxxiv.  p.  107,  1851. 


EI3J:    OF    THE    ACETABULUil.  343 

injury,  and  perliaps  in  obedience  to  circumstances  not  always  easily 
explained. 

The  shortening  has  been  observed  to  vary  from  half  an  inch  to  two 
inches  or  more;  the  trochanter  is  also  usually  driven  in  toward  the 
pelvis.  Pressure  upon  the  trochanter  occasions  a  deep  seated  pain.  If 
the  limb  is  drawn  down  to  the  same  length  with  the  other,  it  imme- 
diately resumes  its  position  when  the  extension  is  discontinued.  Cre- 
pitus is  more  uniformly  present  than  in  fractures  of  the  neck  of  the 
femur,  and  it  is  especially  felt  while  the  limb  is  being  extended  or 
while  it  is  again  shortening,  and  not  so  much  in  flexion  or  rotation. 

If,  in  addition  to  all  of  these  phenomena,  we  learn  that  the  accident 
has  occurred  from  a  severe  blow,  or  a  fall  from  a  great  height  upon 
the  trochanter;  and  that  the  viscera  of  the  pelvis,  and  especially  the 
bladder,  seem  to  have  suffered  considerable  injury;  or  if  we  detect  at 
the  same  time  a  fracture  of  some  other  portion  of  the  pelvis,  we  may 
reasonably  conclude  that  the  head  of  the  femur  has  penetrated  the 
acetabulum.  Yet  it  must  be  confessed  that  no  one  of  these  symptoms 
is  positively  distinctive  of  this  accident,  and  that  they  are  seldom  found 
sufficiently  grouped  to  render  the  diagnosis  certain. 

The  old  "Piper"  mentioned  by  Lendrick,  and  the  man  dissected  by 
Morel-Lavallee,  lived  many  years,  and  managed  to  walk  about,  but 
not  without  considerable  pain  ;  the  other  three,  to  whom  I  have  alluded, 
died  soon  after  the  injuries  were  received. 

Some  have  thought  of  treating  these  cases  by  extension  and  counter- 
extension  ;  the  latter  being  accomplished  through  the  aid  of  a  perineal 
band;  but  it  is  not  probable  that  after  an  injury  of  this  character,  any 
patient  will  be  able  to  endure  the  requisite  pressure  about  the  peri- 
neum or  groins.  It  will  be  better  to  lay  the  patient  upon  Daniel's 
invalid  bed,  or  some  bed  similarly  constructed,  so  that  it  may  be  con- 
verted into  a  double-inclined  plane  ;  allowing  the  knees  to  be  suspended 
over  the  angle  of  the  thigh  and  leg-piece,  in  order  that  the  weight  of 
the  body  may  have  some  effect  to  draw  away  the  pelvis  from  the  femur. 

Fractures  of  the  rim  of  the  acetabulum  have  frequently  been  dis- 
covered in  dissections,  and  the  records  of  surgery  abound  with  cases  of 
unreduced  dislocations  of  the  femur,  in  which  the  failure  to  reduce  or 
to  retain  the  bone  in  place  has  been  ascribed,  not  always  with  sufficient 
reason,  perhaps,  to  this  fracture. 

Dr.  M'Tyer,  of  the  Glasgow  Royal  Infirmary,  published  in  the  Glas- 
gow Medical  Journal^  for  February,  1830,  four  cases  of  this  fracture. 

The  first  was  that  of  a  man,  aet,  27,  on  whose  back  a  number  of 
bricks  had  fallen  while  he  had  his  right  knee  placed  on  the  bank  of  a 
trench.  His  right  leg  was  found  shortened  about  one  inch  and  a  half, 
bent,  and  the  toes  turned  a  little  outwards.  The  limb  could  be  moved 
without  much  difficulty,  but  every  motion  gave  him  pain ;  motion  was 
also  attended  with  crepitus.  On  making  extension,  the  limb  was  easily 
brought  to  the  same  length  with  the  other,  but  it  became  shortened 
again  immediately  when  the  extension  was  discontinued. 

These  symptoms,  differing  but  little,  if  at  all,  from  those  which  are 
usually  present  in  a  case  of  fracture  of  the  neck  of  the  femur,  led  to 
the  supposition  that  this  was  actually  the  nature  of  the  accident.    Sub- 


344  FRACTUEES    OF    THE    PELVIS. 

sequently,  the  toes  became  slightly  turned  in,  but  this  circumstance 
was  not  regarded  as  sufficiently  distinctive  to  warrant' a  change  in  the 
diasnosis. 

Having  succumbed  to  the  injuries  after  a  few  days,  the  autopsy  re- 
vealed a  fracture  extending  through  the  bottom  of  the  right  acetabu- 
lum,  and  about  one  inch  and  a  half  of  the  rim  at  its  upper  and  posterior 
margin  completely  detached,  except  as  it  was  held  in  place  by  a  portion 
of  the  capsular  ligament.  The  head  of  the  bone  could  be  easily  pushed 
upwards  and  backwards  upon  the  dorsum,  the  fragment  of  the  aceta- 
bular margin  being  moved  aside  and  swinging  upon  its  fibrous  attach- 
ment as  upon  a  hinge,  but  resuming  its  place  again  perfectly  when  the 
head  of  the  femur  was  restored  to  the  socket.  The  femur  was  not 
broken. 

In  the  second  case  the  limb  was  found  shortened,  the  knee  slightly 
bent,  and  turned  a  little  forwards  and  inwards,  and  the  toes  pointing 
to  the  tarsus  of  the  other  foot.  It  was  thought  to  be  a  fracture  also  of 
the  neck  of  the  femur,  but  the  autopsy  disclosed  only  a  fracture  of  the 
upper  margin  of  the  rim  of  the  acetabulum. 

In  the  third  case,  seen  only  after  death,  the  limb  was  not  shortened 
much,  but  the  toes  were  stretched  downwards,  and  turned  slightly  in- 
wards. It  was  supposed  at  first  to  be  a  simple  dislocation,  but  on 
dissection  the  posterior  and  inferior  margin  of  the  acetabulum  was 
found  to  be  broken  and  displaced  toward  the  coccyx,  while  the  head  of 
the  femur  rested  upon  the  pyriformis  muscle,  over  the  ischiatic  notch. 

The  fourth  example  was  found  in  the  dissecting-room,  and  the  his- 
tory of  the  case  is  not  known.  A  fragment  of  the  superior  and  posterior 
margin  of  the  acetabulum  had  been  broken  off  and  had  reunited  slightly 
displaced.' 

Several  other  similar  examples  have  been  established  by  dissection, 
and  we  are  able,  therefore,  to  determine  pretty  accurately  what  are  the 
usual  phenomena  and  terminations  of  this  accident,  though  we  are  far 
from  having  arrived  at  a  satisfactory  means  of  diagnosis;  indeed,  the 
accident  has  seldom  been  recognized  before  death.  Its  causes  are 
generally  the  same  with  those  which  produce  dislocations  of  the  hip, 
but  in  most  instances  the  violence  has  been  greater  than  in  the  case  of 
dislocations. 

The  symptoms  are,  first,  such  as  indicate  a  dislocation,  to  which 
must  be  added  crepitus  and  a  difficulty,  if  not  impossibility,  of  retain- 
ing the  head  of  the  femur  in  its  place  when  it  is  reduced.  The  crepitus 
is  sometimes  discovered  the  moment  we  begin  to  move  the  limb,  and 
this  will  aid  us  to  distinguish  it  from  a  fracture  of  the  neck  of  the 
femur  accompanied  with  much  displacement,  since,  in  the  latter  case, 
crepitus  is  not  felt  usually  until  the  extension  is  complete  and  the 
fragments  are  again  brought  into  apposition. 

The  majority  of  these  accidents,  either  from  a  failure  to  recognize 
them  or  from  the  impossibility  of  maintaining  the  head  of  the  femur 
in  place  when  once  it  has  been  reduced,  have  resulted  in  a  permanent 
dislocation  of  the  hip  and  a  serious  maiming.     The  following  case  was 

'  M'Tyer,  Amer.  Jouni.  Med.  Sci.,  vol.  viii.  p.  517,  Aug.  1831. 


EiM  OF  THE  acetabulum:.  845 

recognized  and  reduced,  but  it  was  found  impossible  to  maintain  the 
redaction, 

February  3,  1847,  a  strong  German  laborer  was  crushed  under  a 
mass  of  iron  weighing  several  tons.  Drs.  Sprague  and  Loomis,  of  this 
city,  were  called  and  found  the  left  thigh  dislocated  upwards  and  back- 
wards, and  by  the  aid  of  six  men  they  succeeded  in  reducing  it,  the 
reduction  being  attended,  as  the  gentlemen  have  informed  me,  with  a 
slight  sensation  of  crepitus.  The  legs  were  then  laid  beside  each 
other,  and  the  knees  tied  together,  the  patient  lying  on  his  back ;  and 
now  the  two  limbs  appeared  to  be  of  the  same  length.  On  the  second 
and  third  days  the  injured  limb  was  examined  by  the  same  gentlemen 
and  there  was  no  displacement.  On  the  fourth  day  I  was  invited  to 
meet  these  gentlemen,  the  patient  having  had  muscular  spasms  during 
the  previous  night,  and  the  thigh  being  reluxated.  I  found  the  limb 
shortened  one  inch  and  a  half,  adducted,  and  the  toes  turned  in.  We 
immediately  applied  the  pulleys  and  soon  drew  the  trochanter  down  to 
a  point  apparently  opposite  the  acetabulum,  and  a  careful  measurement 
showed  that  the  two  limbs  were  of  the  same  length.  The  pulleys 
being  removed,  the  leg  did  not  draw  up  again,  nor  did  the  foot  turn 
in,  yet  we  had  felt  no  sensation  to  indicate  that  the  bone  had  slippecT 
into  its  socket,  nor  had  we  felt  crepitus.  The  legs  and  thighs  were 
now  laid  over  a  double  inclined  plane  and  well  secured.  He  remained 
in  this  condition  three  days  more,  during  which  time  Dr.  Sprague  saw 
him  each  day  and  found  nothing  disarranged.  On  the  night  of  the 
seventh  day  the  spasms  returned,  and  in  the  morning  the  thigh  was 
displaced.  The  next  day  we  again  applied  the  pulleys,  but  soon 
found  that  the  bone  would  not  remain  in  place  one  minute  after  the 
pulleys  were  removed. 

At  this  time,  while  moderate  extension  was  being  made  at  the  foot 
by  rotating  the  foot  inwards,  we  could  distinctly  feel  a  slight  crepitus. 
A  straight  splint  was  applied  and  as  much  extension  made  as  he  could 
conveniently  bear,  and  in  this  condition  the  limb  was  kept  several 
weeks.  Seven  years  after  I  found  the  thigh  still  displaced  upon  the 
dorsum  ilii.  He  limped  badly,  but  he  could  walk  fast  and  perform  as 
much  labor  as  before  the  accident. 

In  one  case  mentioned  by  Mr.  Keate  the  bone  had  become  dislocated 
downwards  and  could  be  felt  lying  against  the  tuber  ischii,  and  the 
presence  of  a  "distinct  grating  as  of  ruptured  cartilage"  led  him  to 
conclude  that  the  cartilaginous  labrum  of  the  socket  was  broken  off"; 
but  as  the  fracture  was  on  the  lower  margin  of  the  socket  no  difficulty 
was  experienced  in  retaining  the  bone  in  position.^ 

If  the  diagnosis  is  satisfactorily  made  out,  and  upon  complete  reduc- 
tion the  femur  will  not  remain  in  place,  the  treatment  ought  to  be  the 
same  as  for  a  fracture  of  the  thigh,  except  that  no  lateral  splints  or 
bandages  to  the  thigh  will  be  necessary.  The  limb  ought  to  be  kept 
drawn  out  to  its  proper  length,  as  far  as  this  shall  be  found  to  be 
practicable,  by  extending  and  counter-extending  apparatus.  A  band 
around  the  pelvis,  so  adjusted  as  to  press  the  head  of  the  bone  into  its 

1  Keate,  Amer.  Journ.  of  Med.  Sci.,  vol.  xvi.  p.  225. 


316  FEACTURES    OF    THE    PELVIS. 

socket,  may  also  be  of  service  in  preventing  the  tendency  to  displace- 
ment ;  and  in  case  the  bone  manifests  little  or  none  of  this  tendency, 
the  hip  bandage  will  probably  alone  be  sufficient,  yet  even  here  no 
harm  could  come  of  applying  the  long  straight  splint  and  the  extend- 
ing apparatus,  secured  moderately  tight,  simply  as  a  measure  of  pre- 
caution. 

§  5.  Sacrum. 

Simple  fractures  of  the  sacrum,  known  to  be  exceedingl}'  rare,^  are 
occasioned  either  by  such  injuries  as  break  at  the  same  time  the  other 
bones  of  the  pelvis,  and  which  may  act  in  any  direction,  or  by  blows 
or  falls  received  directly  upon  the  sacrum.  It  may  be  broken  at  any 
point,  and  in  any  direction,  when  the  fracture  is  produced  by  the  first 
of  this  class  of  causes ;  but  if  the  fracture  is  the  result  of  a  direct  blow 
upon  the  sacrum,  it  will  generally  be  transverse,  and  below  the  sacro- 
iliac symphysis.  The  direction  of  the  displacement  is  almost  invari- 
ably the  same,  the  coccygeal  extremity  being  simply  carried  forwards, 
and  this  is  seldom  sufficient  to  interfere  in  any  degree  with  the  func- 
tions of  the  rectum  and  anus;  but  in  one  case  seen  by  Bermond  it 
nearly  closed  the  rectum.  Sometimes,  also,  there  is  a  slight  lateral 
deviation.  There  is  also  in  the  Dupuytren  museum,  at  Paris,  a  speci- 
men in  which  the  whole  of  the  lower  fragment  is  displaced  a  little 
forwards. 

The  signs  of  this  fracture  are  pain  at  the  seat  of  injury,  aggravated 
greatly  in  the  attempts  to  flex  or  elevate  the  body,  and  especially  in 
the  efforts  at  defecation;  swelling  and  discoloration  of  the  soft  parts 
covering  the  sacrum;  displacement  of  the  coccyx  forwards;  an  angu- 
lar projection  at  the  point  of  fracture,  with  a  corresponding  retiring 
angle  upon  the  opposite  side;  mobility. 

Ambrose  Pare  declared  that  he  had  many  times  seen  patients 
recover  after  fractures  of  the  sacrum,  but  if  the  fracture  reaches  the 
spine,  "  scarcely,"  says  he,  "  can  the  patient  escape  death."  Later  ex- 
perience has  shown,  moreover,  that  where  the  fracture  of  the  sacrum 
is  accompanied  with  other  fractures  of  the  pelvis  the  patients  seldom 
recover;  and  only  because  so  extensive  an  injury  implies  usually 
great  force  in  the  cause  which  produced  the  fractures,  and  of  necessity, 
greater  lesions  among  the  pelvic  viscera.  Simple  fractures,  from  direct 
blows,  or  falls  upon  the  sacrum,  occurring  below  the  sacro-iliac  sym- 
physis, are  generally  followed  by  speedy  recoveries,  although  the  in- 
ward displacement  is  not  often  completely  overcome. 

By  introducing  a  finger  into  the  rectum,  the  lower  fragment  can  be 
easily  pressed  back  to  its  natural  position,  but  the  difficulty  consists 
in  finding  any  means  of  retaining  it  there  until  bony  union  is  effected. 
Judes  succeeded  to  his  satisfaction  with  a  wooden  plug,  which  he  com- 
pelled the  patient  to  wear  forty-five  days ;  removing  it,  however,  every 
third  day,  in  order  to  cleanse  the  rectum  with  an  enema.     Bermond 

'  Malgaigne  has  referred  to  eight  cases  ;  and  I  have  not  been  able  to  find  a  record 
of  any  others. 


SACKUM — COCCYX.  347 

introduced  first  a  linen  bag,  which  he  immediately  proceeded  to  fill 
with  lint,  but  during  the  night  it  was  forced  away  in  an  involuntary 
effort  to  empty  the  bowels  of  wind  and  stercoraceous  matter.  He  now 
substituted  a  silver  canula  covered  with  a  shirt,  which  latter  he  filled 
with  lint  in  the  same  manner  as  before.  This  was  retained  without 
much  inconvenience,  nineteen  days ;  having  only  been  removed  once 
during  this  time.  The  union  now  seemed  to  be  firm,  and  the  apparatus 
was  removed.  Plugging  the  rectum  in  this  manner  may  be  necessary 
whenever  the  inward  inclination  of  the  lower  fragment  is  found  to  be 
considerable,  but  not  otherwise;  ordinarily,  it  will  be  sufficient  to  lay 
the  patient  upon  his  back,  with  a  firm  cushion  above  the  point  of 
fracture,  so  as  to  prevent  the  bed  from  pressing  in  the  lower  fragment, 
and  having  emptied  his  rectum  thoroughly  by  an  enema  of  warm 
water,  he  should  be  placed  under  the  influence  of  an  opiate  sufficiently 
to  restrain  the  action  of  the  bowels  for  several  days,  or  for  as  long  a 
time  as  may  be  consistent  with  health  or  comfort.  To  the  same  end, 
also,  the  diet  ought  to  be  light  and  dry ;  nothing  should  be  allowed 
which  might  prove  laxative.  By  constipating  the  bowels,  two  ends 
may  be  gained.  We  shall  prevent  that  frequent  action  of  the  sphinc- 
ters, which  might  tend  to  disturb  the  union ;  and  the  hardened  feces, 
by  their  accumulation  in  the  rectum  may  serve  to  press  back  the  lower 
fragment  of  the  sacrum,  in  a  manner  much  more  natural  and  quite  as 
effective  as  any  apparatus  which  can  be  contrived. 

I  have  already  mentioned  a  case  of  separation  of  the  bones  at  the 
sacro-iliac  symphysis,  reported  by  Lente  (p.  339),  but  which  was  ac- 
companied also  with  a  fracture  of  the  ilium  and  a  dislocation  of  the 
hip.  Several  other  similar  examples  have  been  reported,  in  some  of 
which  both  of  the  sacro-iliac  symphyses  have  been  separated,  or  dis- 
j)laced.  Such  accidents  are  the  results  only  of  great  violence,  and  the 
subjects  of  them  seldom  recover.  In  a  few  instances,  however,  this 
articulation  has  been  known  to  give  way  during  labor,  while  the 
symphysis  pubis  has  suffered  little  or  no  diastasis;  and  in  these  cases 
recovery  has  generally  taken  place. 


§  6.  Coccyx. 

Cloquet  mentions  two  cases  as  having  come  under  his  notice,  one 
produced  by  a  kick,  and  the  other  by  a  fall.  In  the  latter  case  one 
thigh  and  both  legs  were  also  broken,  and  the  coccyx  having  become 
carious  in  consequence  of  the  fracture  was  gradually  exfoliated.^ 

The  symptoms,  mode  of  diagnosis  and  the  treatment  in  case  of  a 
fracture  of  the  coccyx  will  scarcely  demand  of  us  consideration  after 
having  treated  fully  of  these  points  in  their  relation  to  fractures  of  the 
sacrum. 

It  is  more  common,  however,  to  meet  with  examples  of  separations 
of  the  coccyx  from  the  sacrum,  which  may  be  regarded  in  some  cases 
as  veritable  fractures,  and  in  others  as  a  species  of  luxation. 

'  Cloquetj  art.  Bassin,  of  Diet,  en  trente  vol. 


348  FRACTURES    OF    THE    FEMUR. 

Due  to  tlie  same  causes  which  produce  fractures  of  the  coccyx  itself, 
its  symptoms  differ  only  in  the  increased  length  of  the  movable  frag- 
ment, and  its  consequent  greater  projection  in  the  direction  of  its 
displacement.  If  it  is  thrown  forwards,  as  it  usually  is,  the  rectum 
may  be  almost  or  completely  blocked  up  by  its  presence ;  or,  if  it  is 
carried  backwards,  its  pointed  extremity  presses  almost  through  the 
skin. 

Its  mode  of  reduction  and  retention  are  the  same  as  in  fractures  of 
the  coccyx  and  sacrum. 


CHAPTER   XXVIII. 

FRACTUEES    OF   THE    FEMUR. 

Division. — Of  115  fractures  of  the  femur  which  have  come  under  my 
observation,  43  belong  to  the  upper  third,  50  to  the  middle  third,  and 
21  to  the  lower  third ;  or,  if  we  confine  our  analysis  to  the  shaft  alone, 
18  belong  to  the  upper  third,  50  to  the  middle,  and  21  to  the  lower. 

The  femur  constitutes,  therefore,  a  striking  exception  to  the  rule 
which  my  observations  have  established,  that  in  the  case  of  the  long 
bones  the  lower  third  is  most  often  the  seat  of  fracture.  The  femur  is 
most  often  broken  in  its  middle  third. 


§  1.  Neck  op  the  Femur. 

Twenty-four  of  the  whole  number  were  fractures  of  the  neck ;  either 
intra  or  extra-capsular.  The  youngest  of  these  patients  was  thirty- 
nine  years,  the  oldest  eighty-four,  and  the  average  age  was  about 
sixty.  Thirteen  were  males  and  eleven  females.  Nine  occurred  in 
the  right  femur  and  twelve  in  the  left.  All  were  simple.  Six  were 
believed  to  be  without  the  capsule,  and  nine  were  believed  to  be 
within;  the  remainder  were  undetermined. 

Surgeons  have  differed  in  their  opinions  as  to  the  relative  frequency 
of  fractures  of  the  neck  of  the  femur  within  or  without  the  capsule. 
This  has  arisen,  no  doubt,  in  part  from  the  difficulty  and  probable  in- 
accuracy of  many  of  the  diagnoses.  Malgaigne,  who  has  adopted  a 
mode  of  deciding  this  question  which,  it  must  be  conceded,  is  much 
loss  liable  to  error  than  simple  clinical  observation,  namely,  an  exa- 
mination of  cabinet  specimens,  finds  in  four  large  collectioDS  sixty- 
one  intra-capsnlar  fractures,  and  only  forty-two  extra-capsular.  So 
that,  according  to  his  observations,  they  stand  in  the  proportion  of 
about  three  to  two;  the  intra-capsular  being  the  most  common.  On 
the  contrary,  N^laton  believes  that  extra-capsular  fractures  are  much 


NECK    OF    THE    FEMUE. 


549 


the  most  common,  and  Bonnet,  of  Lyons,  affirms  that  thej  constitute 
the  immense  majority.  Bonnet  made  four  dissections,  and  in  each 
case  he  found  the  fracture  extra-capsular.  This  testimony,  so  far  as 
it  goes,  is  positive,  but  the  number  is  not  sufficient  to  establish  any- 
thing more  than  a  probability  in  favor  of  the  greater  frequency  of 
extra-capsular  fractures. 

Clinical  observations  are  too  uncertain  to  be  made  available  in  so 
nice  a  question.  Cabinet  specimens  may  have  been  collected  for 
a  special  purpose,  and  this  is  well  known  to  have  been  the  fact  with 
the  celebrated  Dupuytren  collection,  the  specimens  in  which  constitute 
nearly  one-third  of  the  whole  number  referred  to  by  Malgaigne.  I 
allude  to  the  effort  which  was  made  while  the  controversy  was  pend- 
ing between  Dupuytren  and  Sir  Astley  Cooper  as  to  the  probability 
of  bony  union  in  intra-capsular  fractures,  to  accumulate  cabinet  speci- 
mens of  this  fracture ;  and  which  effort  extended  itself,  no  doubt,  both 
to  London  and  Dublin,  from  which  sources  alone  Malgaigne  has 
gathered  the  balance  of  his  figures.  In  Dr.  Mutter's  collection,  at 
Philadelphia,  I  think  there  are  only  three  examples  of  intra-capsular 
fracture,  to  seven  extra-capsular. 

Dr.  Eeuben  D.  Mussey,  of  Cincinnati,  has  in  his  cabinet  twelve 
examples  of  fractures  of  the  neck  of  the  femur  without  the  capsule, 
and  only  ten  within. 

We  ought,  therefore,  to  regard  the  question  of  relative  frequency 
as  still  undetermined. 


Fig.  100. 


(a.)  Neck  of  the  Femur  within  the  Capsule. 

Causes. — In  no  other  fracture  do  the  predisposing  causes  play  so 
important  a  part  as  in  fractures  of  the  neck  of  the  femur,  and  this 
whether  within  or  without  the  capsule; 
indeed,  experience  has  shown  that  with- 
out the  concurrence  of  those  pathological 
changes  which  usually  accompany  old 
age,  these  fractures  can  scarcely  occur. 
Sir  Astley  Cooper  thought  that  the 
majority  of  fractures  of  the  neck  after 
the  fiftieth  year  were  intra-capsular ; 
but  Robert  Smith  has  given  us  the  ages 
of  sixty  persons  having  fractures  of  the 
neck  of  the  femur,  and  the  average  age 
of  thirty-two  in  whom  the  fractures  were 
within  the  capsule,  is  sixty-two  years, 
while  the  average  age  of  twenty-eight 
in  whom  the  fractures  were  extra-cap- 
sular, is  sixty-eight  years.  Malgaigne 
has  referred  to  this  testimony  in  proof 
of  the  inaccuracy  of  the  opinion  held  by 
Sir  Astley  Cooper ;  but  I  trust  it  will 
not  be  regarded  impertinent  or  hyper- 
critical for  us  to  inquire  how  Mr.  Smith  Fracture  wUhm  the  capsale. 


350  FEACTUEES    OF    THE    FEMUE. 

became  possessed  of  the  ages  of  all  these  persons  from  whom  these 
specimens  were  obtained ;  for  more  than  half  of  the  whole  number, 
that  is,  just  thirty-two,  have  their  ages  set  down  in  round  decimals, 
such  as  60,  60,  70,  &c.,  and  it  would  be  easy  to  show  by  the  inevitable 
law  of  chances  that  this  could  not  possibly  be  a  true  statement.  If  Mr. 
Smith  does  not  pretend  to  have  given  the  ages  with  accuracy,  but  only 
to  have  arrived  as  near  to  the  truth  as  his  sources  of  information  would 
permit,  then  I  protest  that  these  tables  do  not  constitute  proper  evidence 
in  relation  to  this  point;  and  until  better  evidence  is  furnished  I  shall 
continue  to  think,  with  Sir  Astley  Cooper,  that  fractures  within  the 
capsule  belong  generally  to  an  older  class  of  subjects  than  fractures 
without  the  capsule.  This  opinion,' confirmed  by  my  own  experience, 
does  not,  however,  as  Malgaigne  seems  to  think,  imply  that  fractures 
within  the  capsule  may  not  occasionally  occur  in  persons  much  younger 
than  the  average  limit,  namely,  under  fifty  years. 

It  is  also  believed  that  intra-capsular  fractures  are  more  frequent  in 
women  than  in  men. 

The  position  of  the  neck  of  the  femur  and  the  great  thickness  of  its 
muscular  coverings  render  its  fracture  from  a  direct  blow  a  very  rare 
circumstance;  indeed,  it  can  only  happen  as  the  result  of  gunshot  ac- 
cidents, or  other  similar  penetrating  injuries. 

It  is  broken  therefore  usually  by  indirect  blows,  such  as  a  fall  upon 
the  bottom  of  the  foot,  upon  the  knee,  or  upon  the  trochanter  major ; 
or  by  muscular  action  alone,  as  has  sometimes  happened  with  very 
old  people,  who,  in  walking  across  the  floor,  have  tripped  upon  the 
carpet,  breaking  the  bone  in  the  effort  to  sustain  themselves.  We 
must  not  always  infer,  however,  because  the  patient  has  tripped,  that 
the  bone  was  broken  by  muscular  action;  since  it  is  quite  as  likely 
that  the  fall,  consequent  upon  the  tripping,  has  occasioned  the  fracture; 
and  we  ought  to  make  a  careful  examination  of  the  hip  over  the  tro- 
chanter to  ascertain  whether  it  has  been  bruised,  and  to  interrogate 
the  patient  as  to  the  manner  of  the  fall. 

Eodet  has  attempted  to  show  by  a  series  of  experiments  made  upon 
the  dead  subject,  and  by  other  observations,  that  the  direction  in  which 
the  force  has  acted  will  determine  the  situation  and  direction  of  the 
fracture.  Thus  he  maintains  that  when  the  person  has  fallen  upon  the 
foot  or  knee,  the  fracture  will  be  intra-capsular  and  oblique ;  that  if 
the  front  of  the  trochanter  receives  the  blow,  the  fracture  will  be  intra- 
capsular also,  but  transverse ;  if  the  back  of  the  trochanter  is  struck, 
the  fracture  will  be  partly  intra  and  partly  extra-capsular ;  and  if  the 
person  falls  directly  upon  the  side  or  receives  the  blow  fairly  upon  the 
outer  side  of  the  trochanter,  the  fracture  will  be  entirely  without  the 
capsule.^ 

Without  intending  to  give  my  unqualified  assent  to  these  proposi- 
tions so  ingeniously  maintained  by  Eodet,  I  am  nevertheless  prepared 
to  admit  their  general  accuracy;  and  especially  has  my  experience  led 
rne  to  believe  that  falls  upon  the  feet  or  knees  in  most  cases  produce 
intra-capsular  fractures,  and  that  falls  upon  the  outside  of  the  hip,  or 

'  L'Experience,  March  14,  1844. 


NECK   WITHIN    THE    CAPSULE,— EPIPHYSIS.  351 

upon  the  trochanter,  generally  produce  extra-capsular  fractures.  I 
have  seen  also  the  intra-capsular  fracture  produced  by  so  slight  a 
cause  as  stepping  down  unexpectedly  two  or  three  inches  upon  an 
irregular  surface. 

Pathology. — I  have  already,  when  speaking  of  partial  fractures, 
expressed  my  conviction  of  the  possibility  of  a  partial  fracture,  or  a 
fissure  of  the  neck  of  the  femur,  and  I  have  referred  to  the  case  re- 
ported by  Dr.  J.  B.  S.  Jackson,  of  Boston,  as  having  determined  this 
question  beyond  all  possibility  of  a  doubt;  yet  its  occurrence  must  be 
regarded  as  an  exceedingly  rare,  and,  we  may  say,  improbable  event. 

It  is  much  more  common  to  meet  with  examples  of  complete  frac- 
ture of  the  neck  both  within  and  without  the  capsule,  unaccompanied 
with  a  rupture  of  either  the  periosteum  or  the  reflected  capsule.  Such 
was  the  fact  in  eight  cases  examined  by  Colles :  in  three  of  which, 
however,  he  believed  the  fracture  not  to  have  been  complete,  but 
Eobert  Smith  thinks  they  were  all  of  them  examples  of  complete 
fracture.'  Stanley  has  also  related  a  case  of  complete  separation  of  the 
bone  unaccompanied  with  laceration  or  injury  of  either  the  periosteum 
or  capsular  ligament.  This  was  in  the  person  of  a  man  aged  sixty 
years,  who  had  been  knocked  down  in  the  street.  On  being  admitted 
into  St.  Bartholomew's  Hospital,  shortly  after  the  injury,  he  com- 
plained of  pain  in  the  hip,  but  there  was  neither  shortening  nor  ever- 
sion  of  the  limb,  and  its  several  motions  could  be  executed  with 
freedom  and  power.  A  fracture  was  not  suspected;  but  five  weeks 
after  this  he  died  of  inflammation  of  the  bowels.  The  dissection 
showed  a  fracture  extending  through  the  neck  accompanied  with  a 
slight  bloody  effusion,  but  no  displacement  of  the  fragments  or  lacera- 
tion of  the  soft  parts.* 

In  other  examples  the  bone  is  not  only  broken  but  displaced  to 
such  an  extent  that  the  capsule  is  completely  torn  in  two. 

But  in  a  large  majority  of  cases  both  the  capsule  and  the  perios- 
teum are  only  partially  torn  asunder. 

The  fracture  is  generally  somewhat  oblique,  and  its  direction  is 
usually  from  above  downwards  and  from  within  outwards.  Some- 
times its  direction  is  such  as  to  include  a  portion  of  the  head ;  occa- 
sionally it  is  quite  transverse.  In  one  example  of  an  old  fracture  I 
have  seen  the  ends  dove-tailed  upon  each  other,  the  fracture  having  a 
double  obliquity,  and  not  admitting  of  displacement. 

There  may  occur  also  a  species  of  impaction,  the  lower  portion  of 
the  neck  entering  the  cancellous  structure  of  the  head,  while  its  upper 
portion  rides  upon  the  articular  surface,  a  circumstance  which  is  well 
illustrated  by  the  annexed  woodcut  (Fig.  101),  copied  by  Mr.  Smith 
from  a  specimen  in  the  Dupuytren  Museum  at  Paris  ;  or  the  impaction 
may  occur  without  any  degree  of  either  upward  or  lateral  displacement. 

Mr.  Liston  says :  "  Even  in  children  separation  of  the  head  of  the 
bone  may,  on  good  grounds,  be  supposed  occasionally  to  take  place  ;"^ 
by  which  we  understand  him  to  mean  that  a  separation  of  the  epiphy- 

'  Colles,  Dublin  Hosp.  Reports,  vol.  ii.  p.  339. 

^  Stanley,  Med..-Cb.ir.  Trans.,  vol.  xiii. 

3  Liston,  Elements  of  Surgery,  Phila.  ed.,  1837,  p.  480. 


852  FRACTUEES    OF    THE    FEMUE, 

sis  which  completes  the  head  of  the  femur,  may  occur.     Mr.  South 

relates  a  case  in  a  boy  ten  years  of  age, 
Fig.  101.  who  had  fallen  out  of  a  first  floor  window 

upon  his  left  hip.  The  limb  was  slightly 
turned  out,  but  scarcely  at  all  shortened. 
The  thigh  could  be  readily  moved  in  any 
direction  without  much  pain,  but  on  bend- 
ing the  limb  and  rotating  it  outwards,  a 
very  distinct  dummy  sensation  was  fre- 
quently felt,  apparently  within  the  joint,  as 
if  one  articular  surface  had  slipped  off 
another.  This  was  regarded  by  both  Mr. 
South  and  Mr.  Green  as  an  example  of 
epiphyseal  separation,  and  he  was  placed 
upon  a  double  inclined  plane,  but  he  felt 
so  little  inconvenience  from  it  that  he  seve- 
impacted  fracture  within  the  capsule,    ral  tiuics  left  his  bed_  and  Walked  about. 

We  have  no  information  as  to  the  result 
or  as  to  the  farther  progress  of  the  case.' 

A  girl,  get.  18,  was  brought  before  Dr.  Parker,  of  New  York,  at  his 
surgical  clinic,  Nov.,  1850,  who  had  been  injured  by  a  fall  upon  a 
curb-stone,  when  eleven  years  old.  The  accident  was  followed  by 
suppuration  and  a  fistulous  discharge,  from  which,  however,  she  finally 
recovered,  but  with  the  foot  everted,  and  a  shortening  of  one  inch  and 
a  haif  "Flexion  and  rotation  of  the  joint  occasioned  no  inconveni- 
ence." Dr.  Parker  thought  this  circumstance  alone  sufficient  to  dis- 
tinguish it  from  hip  disease  in  which  anchylosis  is  the  termination.^ 

At  a  meeting  of  the  Kappa  Lambda  Society,  held  in  New  York,  March 
25,  1840,  Dr.  Post  mentioned  a  case  which  he  had  seen  in  a  girl  sixteen 
years  old,  who,  in  taking  a  slight  step  with  a  child  in  her  arms,  made 
a  false  movement,  and  feeling  something  give  way,  she  was  obliged  to 
lean  against  a  wall.  Dr.  Post  saw  her  the  next  day,  when  he  found 
the  affected  limb  one  inch  shorter  than  the  opposite  one,  movable,  the 
toes  turned  outwards,  no  swelling,  some  slight  pain  at  the  upper  part 
of  the  thigh.  The  trochanter  major  moved  with  the  shaft.  There  was 
also  crepitus.  From  the  age  of  the  patient  and  the  slight  amount  of 
violence  by  which  the  injury  was  produced,  Dr.  Post  thought  a  sepa- 
ration of  the  epiphysis  of  the  head  had  taken  place.  The  extending 
apparatus  was  applied,  but  the  limb  remains  from  a  quarter  to  half  an 
inch  shorter  than  its  fellow.-'' 

These  three  constitute  the  only  examples  of  this  accident  which  I 
find  reported,  and  although  there  may  be  much  reason  to  suppose  that 
the  diagnosis  was  correct  in  each  instance,  I  cannot  regard  any  one  of 
them  as  actually  proven ;  nor  can  I  admit  the  accident  as  fairly  esta- 
blished, or  the  diagnostic  signs  as  being  properly  made  out  until  these 
important  points  have  received  the  confirmation  of  at  least  one  dissection. 
Symptoms. — Whether  the  limb  will  be  shortened  or  not  must  depend 

'  South,  Note  to  Chelius's  Surgery,  vol.  i.  p.  619. 

■2  Parker,  Amer.  Med.  Gazette,  vol.  i.  p.  342,  Nov.  30,  1850. 

3  Post,  New  York  Journ.  Med.,  vol.  ill.  p.  190,  July,  1840. 


NECK,    WITHIN    THE    CAPSTTLE.  353 

upon  whether  the  fragments  have  become  displaced  in  the  direction  of 
the  axis  of  the  shaft  of  the  femur.  It  is  well  established  that  in  this 
fracture  the  broken  ends  frequently  remain  in  contact  for  several  hours 
or  days,  or  until  the  gradual  contraction  of  the  muscles  or  the  weight 
of  the  body  upon  the  limb  occasions  a  separation,  and  that  conse- 
quently there  is  often  at  first  no  appreciable  or  actual  shortening  of 
the  limb.  To  determine,  however,  its  existence,  it  is  not  suflEicient  to 
lay  the  patient  upon  his  back  and  place  the  limbs  beside  each  other; 
we  ought  also  to  measure  carefully  with  a  tape  line  from  the  pelvis  to 
the  leg  or  foot,  and  from  various  other  points,  until  we  have  placed 
this  question  beyond  a  doubt. 

If  shortening  occurs,  it  may  vary  from  one-quarter  of  an  inch  to  two 
inches,  or  even  more ;  but  this  extreme  shortening  is  not  reached 
usually,  except  after  the  lapse  of  several  weeks  or  months,  when  the 
ligaments  have  gradually  given  way  under  the  weight  of  the  body  in 
walking,  or  not  until  the  neck  has  undergone  a  partial  or  almost 
complete  absorption. 

Sir  Astley  Cooper  has  stated  that  a  shortening  to  this  degree  may  * 
occur  at  once ;  but  Boyer,  Earle,  and  others,  doubt  the  accuracy  of  this 
opinion,  and  Robert  Smith  declares  that  he  does  not  think  the  capsule 
would  admit  of  such  an  amount  of  immediate  displacement,  unless  it 
were  extensively  torn,  an  occurrence  which  he  thinks  very  rare  indeed. 

With  this  qualification,  the  opinion  of  Mr.  Smith  does  not  differ  from 
that  entertained  by  Sir  Astley,  who  only  admits  its  possibility  as  a  rare 
event;  in  a  large  majority  of  cases  the  shortening  does  not  exceed  one 
inch. 

Crepitus,  unlike  shortening,  is  generally  absent  when  the  displace- 
ment of  the  fragments  is  complete;  but  under  no  circumstance  is  it 
easily  developed.  When  the  fragments  remain  in  apposition  and  the 
femur  is  rotated  for  the  purpose  of  moving  the  broken  surfaces  upon 
each  other,  the  small  acetabular  fragment,  resting  in  a  smooth  cup-like 
socket,  and  holding  upon  the  opposite  fragment  by  denticulaiions  or 
by  the  untorn  periosteum  or  capsule,  glides  about  in  obedience  to  the 
motions  of  this  latter,  and  no  crepitus  can  be  produced.  Nor  is  the 
difficulty  rendered  less  by  pressing  firmly  upon  the  trochanter,  as  some 
surgeons  have  recommended,  since,  while  this  pressure  tends,  no  doubt, 
to  fasten  the  upper  fragment  in  the  acetabulum,  it  tends  much  more 
to  fasten  the  broken  ends  together,  and  thus  defeats  the  purpose  in 
view.  When,  on  the  other  hand,  the  fragments  have  become  com- 
pletely separated,  it  is  almost  impossible  to  bring  them  again  into 
contact.  The  limb  may,  perhaps,  be  easily  brought  down  to  the  same 
length  with  the  other,  but  it  must  by  no  means  be  inferred  that,  con- 
sequently, the  broken  ends  are  in  apposition.  It  is  almost  certain, 
indeed,  that  in  its  progress  downwards  the  trochanteric  fragment  has 
caught  upon  the  acetabular  fragment  and  pushed  its  floating  and 
broken  extremity  downwards  before  it.  Under  these  circumstances, 
the  discovery  of  a  crepitus  must  be  accidental,  and  scarcely  to  be 
looked  for.  Sometimes,  however,  we  may  recognize  a  sound  not  un- 
like crepitus,  but  less  harsh,  produced  by  the  friction  of  the  trochan- 
23 


354  FEACTUEES    OF    THE    FEMUE. 

teric  fragment  against  the  rim  of  the  acetabulum  or  dorsum  of  the 
ilium. 

One  thing  we  ought  never  to  forget,  namely,  that  by  extraordinary 
efforts  to  obtain  a  crepitus  we  may  lacerate  the  capsule  or  produce  a 
displacement  of  the  fragments  which  we  never  can  remedy,  and  which, 
without  such  unwarrantable  manipulation,  might  never  have  occurred. 

Eversion  of  the  foot  is  almost  uniformly  present  in  some  degree, 
taking  place  imm.ediately  or  more  gradually,  in  proportion  as  the 
fragments  become  displaced,  and  the  external  rotators  contract.  The 
opposite  condition  or  an  inversion  of  the  foot  is  occasionally  present, 
and  sometimes  also  the  foot  is  neither  turned  in  or  out,  but  the  toes 
point  directly  forwards.  In  sixty  cases  of  fracture  of  the  neck  seen 
by  Cloquet  the  foot  was  never  turned  in,  and  Boyer  never  met  with 
such  an  example  in  all  of  his  immense  experience;  but  Langstaft", 
Guthrie,  Stanley,  and  Cruveilhier  have  each  seen  one  example,  and 
Eobert  Smith  has  seen  two.^ 

The  explanation  of  the  fact  that  the  foot  is  usually  turned  out  is 
simple.  It  is  owing  in  part,  no  doubt,  to  the  natural  position  and 
form  of  the  foot  and  leg,  which  incline  them  to  fall  outwards  by  their 
own  weight,  but  mainly  to  the  powerful  action  of  the  external  rotators, 
which  are  so  feebly  antagonized  upon  the  opposite  side.  But  those 
rare  examples  of  fracture  of  the  neck  of  the  femur  both  within  and 
without  the  capsule,  accompanied  with  a  permanent  or  a  temporary 
inversion  of  the  foot,  are  of  more  difficult  explanation;  and,  indeed,  a 
complete  solution  of  this  phenomenon  does  not  seem  to  have  been  yet 
satisfactorily  reached. 

Fracture  of  the  neck  of  the  femur  within  the  capsule  is  not  usually 
attended  with  much  pain  when  the  patient  is  at  rest,  but  any  attempt 
to  move  the  limb  produces  intense  suffering,  and  especially  when  an 
attempt  is  made  to  rotate  the  limb  inwards,  or  to  carry  it  upwards  and 
inwards. 

Occasionally,  also,  during  the  first  few  days  or  hours  after  the 
fracture,  a  spasmodic  action  of  the  muscles  compels  the  patient  to  cry 
out  from  the  severit}'  of  the  pain  which  it  produces.  At  first,  the 
sufferer  is  unable  to  indicate  clearly  the  seat  of  this  pain,  or,  perhaps, 
it  is  diffused  and  uncertain  in  its  position,  but  after  a  time  he  is  able 
to  refer  it  chiefly  to  the  region  of  the  groin,  opposite  the  neck  of  the 
bone,  or  to  near  the  point  of  attachment  of  the  psoas  magnus  and 
iliacus  internus.  There  is  also  usually  in  this  region  a  great  degree 
of  tenderness  and  an  unusual  fulness. 

If  now  the  limb  be  seized,  and  extension  gradually  but  firmly 
applied,  it  will  soon  be  made  of  the  same  length  with  the  opposite 
thigh ;  but,  the  moment  the  extension  is  discontinued,  the  shortening 
and  eversion  will  recur,  accompanied  with  pain,  and  perhaps  crepitus. 

The  trochanter  major  is  less  prominent  than  upon  the  opposite  side, 
and  if  eversion  of  the  limb  exists,  the  trochanter  may  be  felt  indis- 
tinctly upwards  and  backwards  from  its  usual  position.  The  patient 
having  been  placed   under  the  influence  of  an  anaesthetic,  we  may 

'  Robert  Smith,  op.  cit.,  p.  25.     A.  Cooper  bj  B.  Cooper,  op.  cit.,  p.  151,  note. 


NECK,    TVITHIX    THE    CAPSULE.  355 

prosecute  tbe  investigation  still  further,  and  by  rotating  the  limb  in- 
wards and  outwards  as  far  as  it  will  admit,  we  shall  notice  that  the 
trochanter  describes  the  arc  of  a  smaller  circle  than  in  the  opposite 
limb,  or  that  the  length  of  its  radius  has  been  shortened. 

The  patient  is  generally  unable  to  move  his  limb,  or  to  bear  the 
least  weight  upon  it;  but  many  examples  are  on  record  of  persons 
who  walked  some  distance  after  the  fracture  had  taken  place,  the 
capsule,  and  perhaps,  also,  the  periosteum  not  being  torn,  and,  conse- 
quently, the  fragments  not  being  displaced ;  or,  possibly,  it  was  at 
first  an  impacted  fracture. 

Finally,  after  having  examined  the  patient  as  well  as  we  are  able  to 
do,  in  the  recumbent  posture,  if  any  doubt  remains,  and  it  is  found 
practicable  for  the  patient  to  be  elevated  upon  his  sound  foot,  this 
should  be  done.  The  broken  limb  can  now  be  examined  thoroughly 
on  all  sides,  and  a  more  accurate  opinion  formed  of  the  amount  of 
shortening  and  eversion.  It  will  be  especially  noticed  that  if  the 
weight  of  the  body  is  allowed  to  rest  upon  the  limb  in  the  slightest 
degree  it  produces  insupportable  pain. 

Prognosis. — The  question  of  bony  union  after  a  complete  fracture  of 
the  neck  of  the  femur  within  the  capsule,  has  occupied  the  attention 
of  the  ablest  surgeons  and  pathologists  for  a  long  period;  and  while 
great  differences  of  opinion  have  been  expressed  as  to  the  probability 
of  the  occurrence,  and  as  to  the  value  of  the  testimony  on  the  one  side 
or  the  other,  very  few  have  ventured  to  deny  its  possibility. 

Among  these  latter  are  found,  however,  the  distinguished  names  of 
Cruveilhier,  Colles,  Lonsdale,  and  Bransby  Cooper.  It  has  been 
affirmed,  also,  that  Sir  Astley  Cooper  taught  the  same  doctrine,  but 
with  how  much  show  of  reason,  the  following  paragraphs  from  his 
own  pen  will  determine : — 

"In  the  examinations  which  I  have  made  of  transverse  fractures  of 
the  cervix  femoris,  entirely  within  the  capsular  ligament,  I  have  only 
met  with  one  in  which  a  bony  union  had  taken  place,  or  which  did 
not  admit  of  a  motion  of  one  bone  upon  the  other.  To  deny  the  pos- 
sibility of  this  union,  and  to  maintain  that  no  exception  to  the  general 
rule  can  take  place,  would  be  presumptuous,  especially  when  we  con- 
sider the  varieties  of  direction  in  which  a  fracture  may  occur,  and  the 
degree  of  violence  by  which  it  may  have  been  produced.  For  example, 
when  the  fracture  is  through  the  head  of  the  bone,  with  no  separation 
of  the  fractured  ends ;  when  the  bone  is  broken  without  its  peric;steara 
being  torn  ;  or,  when  it  is  broken  obliquely,  partly  within  and  partly 
externally  to  the  capsular  ligament,  I  believe  that  bony  union  may 
take  place,  although  at  the  same  time  I  am  of  opinion  that  such  a 
favorable  combination  of  circumstances  is  of  very  rare  occurrence. 
Much  trouble  has  been  taken  to  impress  the  minds  of  the  public  with 
the  false  idea  that  I  have  denied  the  possibility  of  union  of  the  fracture 
of  the  neck  of  the  thigh-bone  ;  and  therefore  I  beg  at  once  to  be  under- 
stood to  contend  for  the  principle  only,  that  I  believe  the  reason  that 
fractures  of  the  neck  of  the  thigh-bone  do  not  unite,  is  that  the  liga- 
mentous sheath  and  periosteum  of  the  neck  of  the  bone  are  torn 
through,  that  the  bones  are  consequently  drawn  asunder  by  the  mus- 


356  FEACTUEES    OF    THE    FEMUE. 

cles,  and  that  there  is  a  want  of  nourishment  of  the  head  of  the  bone; 
but  I  can  readily  believe  that  if  a  fracture  should  happen  without  the 
reflected  ligament  being  torn,  that  as  the  nutrition  would  continue,  the 
bone  might  unite;  but  the  character  of  the  accident  would  differ;  the 
nature  of  the  injury  could  scarcely  be  discerned,  and  the  patient's  bone 
would  unite  with  little  attention  on  the  part  of  the  surgeon. 

"  In  proof  of  the  correctness  of  my  opinion,  I  enumerated,  in  the 
early  editions  of  this  work,  forty-three  specimens  of  this  fracture,  in 
different  collections  in  London,  which  had  not  united  by  bone.  At 
the  present  day  these  might  be  multiplied,  were  it  necessary. 

"Such  has  been  the  accumulated  evidence  of  the  want  of  power  of 
the  neck  of  the  femur  to  unite  by  bone,  in  my  practice  of  forty  years, 
during  which  period  I  have  seen  but  two  or  three  cases  which  mili- 
tate against  this  opinion,  for  many  of  the  preparations  which  have 
been  brought  for  my  inspection,  as  specimens  of  united  fractures  of 
this  part,  have  proved  to  be  nothing  more  than  the  result  of  the 
changes  concomitant  with  old  age ;  and  in  many  of  them  the  two 
thigh-bones  of  the  same  subject  had  undergone  the  same  alteration  in 
texture  and  in  form."* 

The  following  passages  from  a  communication  made  by  Sir  Astley 
to  the  London  Medical  Gazette^  for  the  25th  of  April,  1834,  are  equally 
pertinent. 

"I  find  in  a  report  of  the  Baron  Dupuytren's  lecture  that  he  attri- 
butes to  me  the  opinion  that  fractures  of  the  neck  of  the  thigh-bone, 
within  the  capsular  ligament,  not  only  '  never  unite,  but  that  it  is  im- 
possible that  they  should  unite  by  bone.' 

"  It  is  quite  true  that,  as  a  general  principle,  I  believe  that  those 
fractures  unite  by  ligament,  and  not  by  bone,  as  do  those  of  the  patella 
and  olecranon.  But  I  deny  that  I  have  ever  stated  the  impossibility 
of  their  ossific  union;  on  the  contrary,  I  have  given  the  reason  why 
they  may  occasionally  unite  by  bone. 

"  The  following  are  my  words :  '  To  deny  the  possibility  of  their 
union,  and  to  maintain  that  no  exception  to  this  general  rule  may 
take  place,  would  be  presumptuous,' "  &c.  &c. 

In  conclusion.  Sir  Astley  remarks:  "I  should  not  have  given  you 
this  trouble,  nor  should  I  have  taken  it  myself,  but  for  the  respect  I 
bear  my  friend,  the  Baron  Dupuytren  ;  for  although  I  have  already 
submitted  myself  to  be  misrepresented  by  many  individuals,  yet  I 
should  be  sorry  to  be  misundei'stood  by  so  excellent  a  surgeon,  and  so 
valuable  a  friend,  as  Le  Baron  Dupuytren."^ 

What  apology  now  can  be  found  for  a  writer  who,  in  a  lecture 
before  the  Royal  College  of  Surgeons,  delivered  so  .late  as  the  year 
1858,  uses  the  following  language : — 

"  It  is  well  known  that  Sir  Astley  Cooper  always  taught  the  doc- 
trine that  fractures  of  the  neck  of  the  thigh-bone  were  incapable  of 
being  repaired  by  osseous  matter,  and  that  in  the  whole  course  of  his 

'  Sir  Astley  Cooper,  on  Dislocations  and  Fractures  of  the  Joints,  edited  by  Bransby 
Cooper,  Amer.  ed.,  p.  156. 

^  See  also  Sir  Astley's  letter  to  Prof.  Cox,  written  in  1835,  and  published  in  the  Prov. 
Med.  and  Surg.  Journ.  for  July  12,  1848,  and  New  York  Journ.  Med.  for  Sept.  1848. 


NECK,   WITHIN    THE    CAPSULE.  357 

practice  he  had  never  met  with  a  single  instance,  nor  could  he  meet 
with  any  one  who  had  seen  a  case  where  such  an  occurrence  had 
happened;  and  that  union  within  the  capsular  ligament  (when  any 
such  union  takes  place)  is  always  by  membrane.  However,  it  appears 
that  he  had  no  sooner  published  the  last  edition  of  his  work  Oyi  Frac- 
tures and  Dislocations^  than  Mr.  Swan  forwarded  to  him  a  specimen  of 
the  thigh-bone,  in  which  the  fracture  of  the  neck  had  become  reunited 
by  osseous  matter.  Sir  Astley  retained  the  specimen  until  his  death, 
and  it  appears  that  he  never  had  the  courage  or  policy  to  promulgate 
the  discovery  of  the  error  of  that  doctrine  which  had  so  pervaded 
his  miad,  and  which  had  misled  the  profession  during  a  period  of  forty 
years.'" 

What  pusillanimity  is  apparent  in  this  repetition  of  a  slander  which 
had  been  refuted  a  hundred  times  by  Sir  Astley,  but  who,  being  now 
dead,  might  be  assailed  with  impunity!  Do  not  the  surgeons  of  the 
Royal  College  who  listened  to  these  ungenerous  insinuations,  know 
full  well  their  falsity?  or  is  it  possible  that  they  derived  a  secret  plea- 
sure in  hearing  these  insults  cast  upon  one  who,  although  he  had  done 
more  than  any  other  man  to  exalt  the  fame  of  English  surgery,  had, 
nevertheless,  been  only  lately  their  rival,  and  from  the  shadow  of 
whose  colossal  form  they  were  just  beginning  to  emerge  into  light. 
Sir  Astley,  so  far  from  denying,  frankly  admitted  its  possibility,  and 
explained  the  circumstances  under  which  he  believed  it  might  occur. 
The  true  point  in  dispute  was,  whether  certain  cabinet  specimens 
were  actually  examples  of  complete  fractures,  wholly  within  the  cap- 
sule, united  by  bone.  Some  of  them  Sir  Astley  thought  were  only 
examples  of  chronic  rheumatic  arthritis,  or  of  interstitial  and  progres- 
sive absorption.  Some  were  partial  rather  than  complete  fractures  ; 
others  were  partly  within  and  partly  without  the  capsule;  and  for  this 
he  was  accused  of  wilful  blindness  or  stupidity,  chiefly  by  those  who 
themselves  being  the  owners  of  these  rare  pathological  treasures,  might 
possibly  have  felt  somewhat  annoyed  at  seeing  their  value  thus  depre- 
ciated, and  who,  no  doubt,  would  be  quite  as  apt  to  fall  into  blindness 
and  partisanship  as  Sir  Astley  himself.  The  truth  is,  however,  that 
although  the  claim  has  been  set  up  and  stoutly  maintained  for  more 
than  thirty  cabinet  specimens,  in  one  part  of  the  world  or  another,  a 
majority  of  these,  including  several  whose  claims  were  urged  upon  Sir 
Astley,  have  been  at  length  declared  by  all  parties  unsatisfactory,  or 
absolutely  fictitious,  and  only  a  fraction  of  the  whole  number  continue 
to  be  mentioned  by  any  surgical  writer  as  probable  examples.^ 

'  Lettsomian  Lectures  on  the  Physical  Constitution,  Diseases  and  Fractures  of  Bones, 
by  John  Bishop,  F.  R.  S.     London,  1855,  p.  55. 

^  The  following  European  surgeons  have  claimed  to  have  in  their  possession,  each, 
one  example  :  Langstaflf  (Med. -Chir.  Trans.,  vol.  xiii.  1827)  ;  Brulatour  (Ibid.,  vol.  xiii. 
1827) ;  Stanley  (Ibid.,  vol.  xviii.)  ;  Swan  (Swan  on  Diseases  of  Nerves,  p.  304)  ;  Adams 
(Todd's  Cyclop.,  p.  813)  ;  Jones  (Med. -Chir.  Trans.,  vol.  xxiv.)  ;  Chorley  (Amesbury 
on  Frac,  p.  125)  ;  Field  (Ibid.,  p.  128)  ;  Soemmering  (Chelius's  Surgery  by  South,  vol. 
i.  p.  621)  ;  South  (Ibid.,  p.  621).  South  also  mentions  another  example  as  being  in 
the  museum  of  St..  Bartholomew's  Hospital.  This  is  probably  Jones'  case,  which  Robert 
Smith  says  is  preserved  in  this  museum,  and  which  has  already  been  enumerated. 
Bryant  (Memphis  Med.  Rec,  vol.  vi.  p.  108,  from  British  Med.  Journ.,  March  14); 


358  FRACTUEES  OF  THE  FEMUR. 

Eobert  Smith  reduces  the  number  to  seven,  but  Ma]gaigne  recog- 
nizes only  three,  namely:  Swan's  case,  admitted  by  Sir  Astley  himself; 
Stanley's  case,  and  one  specimen  in  the  Dupuytren  museum.  In 
neither  of  these  cases,  he  affirms,  has  the  neck  lost  anything  of  its  form 
or  length  by  absorption,  from  which  we  are  to  infer  that  he  would 
reject  as  doubtful  all  such  specimens  as  had  undergone  these  patho- 
logical changes. 

Indeed,  I  think  we  are  not  left  in  doubt  as  to  Malgaigne's  opinion 
upon  this  point.  Six  of  the  nineteen  cases  which  I  have  enumerated 
are  declared  by  him  to  resemble  much  more  rachitic  alterations  of  the 
neck  than  true  fractures ;  and  yet  Robert  Smith  admits  three  of  the 
six  as  well  established  examples ;  but  as  to  the  precise  grounds  upon 
which  he  rejects  these  cases,  he  shall  speak  for  himself:  "And  it  is 
sufficient  that  we  consider  the  beautiful  drawings  designed  by  Sir 
Astley  Cooper,  to  illustrate  certain  varieties  of  the  alterations,  to  place 
us  on  our  guard  against  every  pretended  consolidation  which  presents 
itself,  accompanied  with  a  shortening  and  deformity  of  the  head  and 
neck.  When  fractures  unite  by  bone  they  do  not  suffer  such  enormous 
losses  of  substance  which  it  would  become  necessary  to  admit  for  the 
neck  of  the  femur."^ 

A  reference  to  Stanley's  case,  as  reported  by  Robert  Smith,  will 
show  that,  contrary  to  Malgaigne's  statement,  this  was  also  shortened 
and  deformed,  ancl  that,  consequently,  according  to  his  own  rules  of 
exclusion,  it  also  must  be  rejected;  after  which  only  two  remain, 
namely,  Swan's  case,  admitted  by  Sir  Astley  himself,  and  No.  188  of 
the  Dupuytren  museum. 

I  should  do  injustice  to  my  own  convictions,  moreover,  were  I  not 
to  refer  my  readers  to  the  following  judicious  criticism  upon  Mr.  Swan's 
case : — 

"Mr.  Smith's  notes  are  as  follows:  'Mrs.  Powel,  above  eighty  years 
of  age,  fell  down,  November  14,  1824.  Sir  Astley  Cooper,  who  saw 
her  soon  after,  believed  that  there  was  a  fracture  of  the  neck  of  the 
femur,  although  there  was  no  appreciable  shortening  of  the  limb,  and 
only  a  slight  inclination  of  the  toes  outwards ;  crepitus  could  not  be 
perceived;  the  patient  died  about  five  weeks  after  the  accident;  upon 
examination  of  the  joint  after  death,  the  fracture  was  found  to  have 
been  entirely  within  the  capsular  ligament,  and  the  greater  part  of  it 
was  firmly  united.  A  section  was  made  through  the  fractured  part, 
and  a  faint  white  line  was  seen  in  one  portion  of  the  union,  but  the 
rest  appeared  entirely  of  bone.  The  cervical  ligament  had  not  been 
injured.'"  {Smith,  page  59.)  In  this  case  the  patient  was  an  old  lady, 
above  eighty  years  of  age,  with  the  fracture  not  certainly  made  out; 
there  was  no  appreciable  shortening  of  the  limb;  no  crepitus;  and 

Fawdington  (Amer.  Joum.  Med.  Sci.,  vol.  xv.  p.  534,  from  London,  Med.  Gaz.,  Aug. 
16,  1834)  ;  Harris  (Ibid.,  vol.  xviii.  p.  246,  from  Dublin  Joum.,  Sept.  1835).  Robert 
Hamilton  says  that  Prof.  Tilanus  showed  him  three  specimens  in  the  museum  of  the 
Hosjiital  of  St.  Peter,  at  Amsterdam  (Ibid.,  vol.  xxxi.  p.  470,  from  Lend.  Med.  Gaz., 
Jan.  6,  1843).  Malgaigne  says  there  are  three  specimens  in  the  Dupuytren  museum 
which  have  been  described  with  the  same  interpretation.  The  whole  number  claimed 
by  transatlantic  surgeons  is  therefore  nineteen. 

'  Malgaigne  Traite  des  Fractures  et  des  Luxations,  tom.  i.  p.  678. 


NECK,    WITHIN    THE    CAPSULE.  359 

only  a  slight  inclination  of  the  toes  outwards.  The  strongest  point  in 
favor  of  there  having  been  a  fracture,  was  the  opinion  of  Sir  Astley 
Cooper,  which  opinion  is  entitled  to  great  weight;  but  there  are  no 
satisfactory  facts  given  upon  which  he  formed  that  opinion.  This 
slight  eversion  of  the  foot  might  be  given  by  the  patient  to  relieve  the 
tension  on  the  bruised  and  inflamed  part.  We  may  well  query  if  the 
vessels  of  the  ligamentum  teres  would  not  have  shown  evidences  of 
having  performed  an  increased  function?  Would  five  weeks  have 
been  sufficient  time  for  them  to  furnish  osseous  union,  and  resume  their 
original  size  ? 

"Again,  the  old  woman  died  in  five  weeks  after  the  receipt  of  the 
injury.  Now,  it  seems  to  us  quite  improbable,  nay,  impossible,  that 
bony  union  of  an  intra-capsular  fracture  of  the  femur  in  an  old  woman, 
above  eighty  years  of  age,  in  whom  there  was  not  left  vitality  enough 
to  sustain  life,  should  take  place,  in  five  weeks  after  the  injury,  in  less 
time  than  is  allowed  for  the  ordinary  union  of  a  fracture  of  the  shaft 
of  the  femur  in  a  healthy  person  in  the  prime  of  life.'" 

On  this  side  of  the  Atlantic,  the  number  of  specimens  for  which 
the  honor  is  claimed  is  nearly  equal  to  the  original  number  in  Europe ; 
but  they  have  not  yet,  all  of  them,  been  subjected  to  the  same  sifting 
process  as  their  foreign  congeners;  and  it  remains  to  be  seen  how  many 
of  them  will  come  successfully  out  of  a  similar  fifty  years'  contest. 

Three  of  the  specimens  belong  to  the  venerable  and  distinguished 
surgeon,  Reuben  D.  Mussey,  Professor  of  Surgery  in  the  Miami  Medi- 
cal College,  at  Cincinnati,  Ohio,  and  whose  many  valuable  contribu- 
tions to  the  science  which  he  has  so  long  adorned  are  familiar  to  all 
American  surgeons.  He  has  also  himself  furnished  a  complete  history 
and  description  of  the  specimens,  accompanied  with  drawings,  which 
is  published  in  the  April  number  for  1857  of  the  American  Journal  of 
the  Medical  Sciences. 

The  first  patient  was  a  Mr.  S.,  a3t.  78,  a  hardy  yeoman  from  one  of 
the  hilly  districts  of  Northern  New  England.  When  more  than  one 
hundred  miles  from  home,  his  two-horse  wagon  was  upset,  and  falling 
upon  his  hip  he  was  so  much  injured  as  to  be  unable  to  rise.  Dr.  J. 
C.  Dalton,  of  Lowell,  Massachusetts,  a  highly  distinguished  gentleman, 
examined  the  limb,  and  pronounced  it  a  fracture  of  the  neck  of  the 
thigh-bone,  and  accordingly  he  applied  a  modified  Desault's  apparatus. 

On  the  fourth  or  fifth  day,  contrary  to  the  remonstrances  of  his 
surgeon,  the  man  had  himself,  apparatus,  and  bed  placed  in  a  long  box, 
and  the  v/hole  being  laid  in  a  country  wagon  he  started  for  home. 
On  the  eighteenth  day  of  the  accident,  after  reaching  home,  and  while 
yet  in  the  box  and  apparatus,  Dr.  Mussey  was  called  to  see  him.  On  re- 
moving the  bedclothes  Dr.  Mussey  noticed  that  the  foot  and  knee  were 
turned  considerably  outwards.  He  immediately  took  off  the  splint, 
and  moved  the  hip-joint;  finding  that  it  gave  him  no  pain,  he  flexed  the 
thigh  to  a  right  angle  with  the  body,  and  kept  it  a  minute  or  two  in 
that  position,  still  occasioning  no  pain,  but  on  flexing  it  a  little  further 

1  An  inaugural  thesis  on  intra-capsular  fractures  of  the  cervix  femoris,  by  John  Geo. 
Johnson,  New  York,  1857,  p.  23.     New  York  Journ.  Med.,  3d  ser.,  vol.  ii.  p.  295. 


360 


TRACTURES    OF    THE    FEMUR. 


he  complained  that  it  hurt  him  in  his  groin.  Pressure  with  the  finger 
at  this  point  and  behind  the  trochanter  gave  him  decided  uneasiness. 
No  shortening  could  be  detected. 


Fig.  102. 


Fig.  103. 


Left,  or  injured  femur,  of  Mr.  S. 


Vertical  section  of  the  same. 


Fig.  104. 


Dr.  Mussey  now  felt  so  confident  that  the  bone  was  not  broken  that 
he  asked  the  old  gentleman  if  he  wished  to  get  up,  and  upon  his  reply- 
ing in  the  affirmative  he  was  helped 
into  a  chair  and  sat  for  some  time.  He 
also  bore  the  weight  of  his  body  for 
a  minute  or  two  upon  his  limb.  From 
that  day  onward  he  wore  no  splint, 
and  was  got  from  his  bed  daily.  In 
the  course  of  four  months  the  patient 
was  able  to  walk  with  a  cane,  but  he 
remained  lame,  and  was  never  able 
again  to  ride  on  horseback  as  he  had 
been  accustomed  to  do. 

Dr.  Dalton  hearing  of  Dr.  Mussey's 
opinion,  wrote  to  him  that  on  his  visit 
to  the  patient  he  found  the  limb  not 
only  everted  but  shortened  more  than 
an  inch,  and  that  he  had  detected  cre- 
pitus. Yet  this  does  not  seem  to  have 
changed  Dr.  Mussey's  belief  that  it  was 
not  broken. 

Two  or  three  years  after  this  the 
man  died  of  an  acute  disease.  Both 
thigh-bones  were  obtained.  The  right  femur  was  sound  (Fig.  104),  but 
on  being  carefully  cleaned  the  neck  of  the  left  femur  was  found  to  be 
shortened,  so  that  in  front  it  measured  from  the  head  to  the  inter- 
trochanteric line  one  inch  and  three-eighths,  and  behind  only  one-third 


Eigh-t,  or  sound  femur  of  Mr.  S. 


XECK,    TTITHIX    THE    CAPSULE,  861 

of  an  inch,  the  shaft  being  rotated  outwards.  The  head  was  sunk 
below  the  level  of  the  top  of  the  trochanter  major,  occasioning  a  short- 
ening of  more  than  half  an  inch.  "A  vertical  section''  (Figs.  102, 
103),  savs  Dr.  ^Slussey,  "made  by  a  saw,  shows  a  consolidation  of  the 
fracture  by  a  deposit  of  a  mass  as  compact  and  white  as  ivory." 

"  In  the  year  1880,"  he  continues,  "  I  showed  this  to  Messrs.  Eoux 
and  Amussat,  and  some  other  professional  gentlemen  in  Paris ;  they 
regarded  it  as  a  fair  specimen  of  bony  union  of  intra-capsular  fracture. 
In  London  I  also  showed  it  to  Mr.  Lawrence,  Mr.  Travers,  Mr.  Stanley, 
and  Dr.  Hodgkin,  who  was  then  Curator  of  the  Museum  at  Guy's 
Hospital,  These  gentlemen  were  interested  with  the  specimen,  and 
considered  it  as  a  satisfactory  example  of  bony  union  within  the  cap- 
sular ligament.  On  my  presenting  it  for  inspection  to  Sir  Astley  Coo- 
per, he  remarked,  'This  bone  never  was  broken.'  I  said,  'Sir  Astley, 
please  to  look  at  the  interior  of  the  bone.'  He  separated  the  two 
halves,  and  said,  'This  does  look  a  little  more  like  it,  to  be  sure;  but 
I  do  not  think  it  is  wholly  within  the  capsular  ligament.'  It  is  well 
known  that  Sir  Astley,  for  some  years,  had  taught  the  doctrine  that 
bony  union  does  not  take  place  in  intra-capsular  fracture.  His  views, 
among  the  surgeons  of  Great  Britain,  were  extensively  admitted  as 
correct," 

At  Edinburgh,  Dr,  Mussey  also  showed  the  specimen  to  John 
Thompson,  author  of  the  great  work  on  inflammation,  who  called  it 
an  example  of  absorption,  kc,  consequent  upon  old  age,  and  affirmed, 
"upon  his  truth  and  honor,"  that  it  had  never  been  broken. 

Dr.  Mussey  says,  moreover,  that  the  surgeons  in  this  country,  "who 
have  examined  these  specimens,  unhesitatingly  pronounce  this  to  be  a 
case  of  union  by  bone  of  intra-capsular  fracture." 

There  are  one  or  two  points  in  this  case  which  give  it  extraordinary 
claims  to  attention.  The  first  circumstance  is  the  shortening  discovered 
by  Dr.  Dalton,  and  which  was  absent  on  the  eighteenth  day,  when  the 
limb  was  examined  by  Dr.  Mussey.  One  of  these  two  gentlemen  was 
mistaken.  If  it  had  united,  the  bones  were  never  completely  displaced, 
and  it  could  not  have  been  shortened  when  Dr.  Dalton  first  saw  it. 
This  position  I  need  not  now  attempt  to  defend  ;  the  testimony  of 
all  surgeons  who  have  written  upon  this  subject  will  warrant  me  in 
assuming  thus  much.  Again,  if  it  had  been  thus  displaced,  and  Dr. 
Dalton  had  restored  it  to  place,  it  seems  impossible  that,  after  a  jour- 
ney of  one  hundred  miles  over  a  rough  country  in  a  wagon,  on  the 
eighteenth  day  it  should  not  have  been  again  displaced  and  shortened, 
and  especially  if  at  this  time  the  thigh  was  not  only  flexed  to  an  acute 
angle  upon  the  bod}^  but  the  patient  was  permitted  to  stand  upon  it. 
If,  however.  Dr.  Mussey  still  maintains  that  the  limb  was  not  shortened 
when  he  examined  it,  it  remains  for  him  to  show  how  the  bone  was 
brought  to  position,  and  afterward  kept  in  place  so  effectually,  under 
such  unfavorable  circumstances;  or  if  he  admits  that  the  shortening 
existed  at  that  time,  but  was  overlooked  by  him,  then  we  must  inquire, 
When  (subsequently,  of  course)  was  the  bone  set?  and  how  does  it 
happen  that  it  has  united  at  all?  There  must  have  been  a  mistake 
somewhere  in  relation  to  this  matter  of  shortening;  and  if  so,  with  all 


362 


FRACTURES    OF    THE    FEMUR. 


Fig.  105. 


my  respect  for  Dr.  Dalton,  whose  veracity  and  skill  no  man  will  dare 
to  question,  I  am  sceptical  also  as  to  the  existence  of  crepitus.  It  is 
not  entirely  clear  to  me  that  he  was  not  deceived. 

In  the  history  of  the  case,  then,  we  see  no  reliable  evidence  of  a 
fracture  either  within  or  without  the  capsule,  nor  did  Dr.  Mussey  be- 
fore the  death  of  the  patient.  The  bone  itself,  however,  has  convinced 
Dr.  Mussey  that  it  was  broken  within  the  capsule,  and  that  it  is  well 
united  by  ossific  matter.  I  have  not  seen  it,  and  therefore  am  an 
incompetent  judge  of  its  value;  but  I  must  acknowledge  that  neither 
the  description  nor  the  drawing  furnishes  me  with  any  positive  proof 
that  it  was  ever  broken,  and  still  less  that  the  fracture  was  wholly 
within  the  capsule.  Sir  Astley  Cooper  doubted  whether,  if  it  was  a 
fracture  at  all,  it  was  a  fracture  wholly  within  the  capsule ;  and  I  am 
willing  to  leave  the  question  between  these  distinguished  gentlemen 
as  they  have  themselves  left  it,  each  one  of  whom  was,  in  my  opinion, 
equally  earnest  and  sincere  in  his  convictions,  and  each  one  of  whom 
was  equally  competent  to  decide  the  point  at  issue. 

Dr.  Mussey 's  second  specimen  was  obtained  from  a  Mr,  N.,  who, 
when  fifty-one  years  old,  fell,  in  alighting  from  his  chaise,  striking 

upon  his  left  hip.  He  was  unable  to 
wallv.  Dr.  Mussey  saw  him  on  the  third 
day,  and  found  him  a  corpulent  man, 
lying  with  his  foot  everted,  and  the  limb 
shortened  from  one  inch  to  one  inch  and  a 
third.  He  could  extend  the  leg  to  within 
about  one-third  of  an  inch  of  its  natural 
length,  and  when  thus  extended  and 
rotated  a  distinct  crepitus  was  produced. 
He  applied  Hartshorne's  long  splint, 
which  was  continued  eighty-four  days, 
the  extension  never  being  sufficient,  how- 
ever, to  completely  overcome  the  short- 
ening. He  ultimately  walked  with  a 
cane,  the  shortening,  which  was  about 
half  an  inch,  being  concealed  by  a  high- 
heeled  shoe. 

This  man  survived  the  injury  twelve 
years,  and  eight  years  after  his  death  Dr. 
Mussey  obtained  the  specimen  of  injured 
bone  (Fig.  105),  together  with  its  fellow  (Fig  107).  The  head  of  the 
injured  bone  is  elongated  and  depressed,  or  flattened,  the  neck  is  very 
much  shortened,  and  the  trochanter  turned  back  as  in  the  first  speci- 
men. A  section  (Fig.  106)  shows  a  white,  condensed  tissue  travers- 
ing the  neck,  near  its  junction  with  the  head. 

Mrs.  Mason,  set.  73,  was  the  subject  of  the  third  accident.  She  was 
a  small,  thin  woman,  and  had  fallen  upon  her  side.  Two  days  after. 
Dr.  Mussey  saw  her  in  consultation  with  his  friend.  Dr.  Judkins.  The 
knee  and  foot  were  a  little  everted,  with  slight  shortening  and  tender- 
ness on  pressure  in  the  groin  and  behind  the  trochanter  major.  She 
was  averse  to  the  application  of  any  kind  of  splint,  and,  being  in  a 


The  left,  or  injured  femur  of  Mr.  N. 


NECK,   WITHIN    THE    CAPSULE. 


363 


delicate  state  of  health,  she  was  allowed  to  remain  upon  her  couch, 
with  the  thigh  and  leg  somewhat  flexed  and  supported  by  a  pillow. 

Fig.  107. 


Vertical  section  of  the  injured  femur  of  Mr.  N. 


The  right,  or  sound  femur  of  Mr.  N. 


She  remained  in  this  situation  about  three  months,  after  which  she 
could  move  with  the  aid  of  crutches.  She  died  in  a  year  and  a  half 
from  the  accident,  worn  out  by  age  and  exhaustion. 


Fig.  108. 


Fis.  109. 


The  right,  or  injured  femur  of  Mrs.  M. 


Vertical  section  of  the  injured  femur  of  Mrs.  M. 


The  neck  of  the  bone  (Fig,  108)  is  shortened  to  seven-eighths  of  an 
inch  anteriorly,  and  to  half  an  inch  posteriorly.  A  considerable  ridge 
runs  across  the  anterior  part  of  the  neck,  between  which  and  the  head 
is  an  irregular  superffcial  groove.  A  section  of  the  bone  (Fig.  109) 
presents  "a  narrow,  white,  eburnated  line,  corresponding  with  the 
aforesaid  ridge,  exhibiting  a  firm  consolidation." 

I  shall  express  no  opinion  of  these  two  last  described  specimens 
further  than  to  say  that  they  seem  to  be  liable  to  the  same  objections 
as  several  others  of  which  I  have  already  spoken,  and  that  the}"  do 
not  belong  to  that  class  which  has  alone  been  accepted  by  Malgaigne. 


864  FRACTURES    OF    THE    FEMUR. 

It  is  proper,  however,  to  say  that,  according  to  Dr.  Johnson,  in  the 
paper  already  referred  to,  some  of  the  surgeons  who  have  examined 
these  specimens  have  declared  to  him  that  they  were  not  satisfactory. 

Says  Dr.  Johnson,  in  the  same  paper: — 

"In  regard  to  the  Philadelphia  specimens,  my  only  source  of  in- 
formation is  the  brief  notice  of  them  in  the  new  work  on  surgery  by 
Prof.  H.  H.  Smith,  of  Philadelphia.  His  statement  is  as  follows  (page 
899) :  '  There  is,  in  the  Wistar  and  Horner  Museum  of  the  University 
of  Pennsylvania,  a  femur,  apparently  of  an  old  woman,  in  which  the 
neck  has  been  fractured  near  the  head,  yet  in  which  complete  osseous 
union,  though  with  some  degree  of  shortening,  has  taken  place.  I 
have,  moreover,  in  my  own  cabinet  a  specimen  in  which  the  bone  has 
been  fractured  through  the  neck  near  the  head,  the  fragment  having 
slid  down  beneath  its  natural  position,  and  the  fracture  travelled 
obliquely  down  the  neck,  though  still  within  the  capsule,  splitting  it 
off  in  the  line  of  the  inter-trochanteric  ridge.  In  this  case,  which 
must  have  produced  marked  shortening  of  the  limb,  there  is  complete 
osseous  union.'  This  report  is  so  exceedingly  brief  that  no  inference 
can  be  drawn  from  it ;  in  fact,  the  writer  does  not  appear  to  know 
whether  the  specimen  is  from  a  male  or  female.  If  this  is  true,  then 
he  knows  nothing  of  the  history  of  it.  He  does  not  give  us  the  direc- 
tion of  the  fracture,  or  a  drawing  of  it,  or  even  a  positive  statement 
that  it  is  entirely  within  the  capsule.  In  regard  to  his  own  specimen 
he  is  more  explicit;  he  gives  a  drawing  and  shows  that  the  fractured 
head'  has  slipped  down,  and  even  now  the  line  of  fracture  can  be 
traced  to  the  inter-trochanteric  line.  If  this  is  so  now,  it  is  probable 
that  the  end  of  the  fractured  bone  extended  below  the  capsule  in  the 
first  place,  as  in  all  cases  of  fracture,  where  there  is  not  perfect  coapta- 
tion, the  rough  points  become  absorbed.  If  we  allow  for  this  absorp- 
tion, it  would  make  the  end  of  the  bone  below  the  trochanteric  line  a 
point  without  the  capsule,  thus  excluding  it  from  this  class.  If  we 
adopt  Prof.  Smith's  view,  that  this  was  entirely  within,  we  meet  with 
this  objection.  He  states  that  the  head  of  the  bone  has  slipped  down 
beneath  its  natural  position,  and  the  fracture  has  traversed  it  obliquely. 
This,  of  course,  could  not  have  been  an  impacted  fracture,  for  in  an 
impacted  fracture  we  should  have  had  the  shaft  of  the  bone  driven 
into  the  cancellated  portion  of  the  head,  not  the  head  of  the  bone 
'slipping  down'  along  the  shaft.  If  this  was  a  case  of  slipping  down 
of  the  head,  we  leave  Prof.  Smith,  of  Philadelphia,  to  controvert  the 
position  taken  by  Mr.  Smith,  of  Dublin,  where  he  says  that  only 
impacted  intra-capsular  fractures  can  have  an  osseous  union." 

Speaking  of  a  specimen,  also,  which  may  be  found  in  the  Crosby- 
street  Medical  College,  of  New  York,  he  says  : — 

"This  belongs  to  Prof.  Willard  Parker,  of  this  city.  I  am  under 
obligations  to  Prof.  Parker,  for  his  kindness  in  explaining  to  me  the 
various  points  which  he  considers  the  case  presents.  He  loaned  me 
the  specimen  to  examine  at  my  leisure,  that  I  might  become  thoroughly 
acquainted  with  all  the  facts  of  the  case.  According  to  the  description 
of  the  case  given  by  Prof.  Parker,  in  his  lecture,  the  patient  was  a 
maiden,  about  sixty  years  of  age,  an  inmate  of  the  almshouse  of  Bar- 


NECK,   WITHIN    THE    CAPSULE.  365 

nard,  Yt.  One  morning,  while  going  out  of  doors,  she  fell,  striking 
upon  her  hip.  The  doctor  in  attendance,  who  did  not  pretend  to  be 
a  surgeon,  or  accurate  in  his  diagnosis,  came  to  the  conclusion  that 
there  was  a  fracture.  He  was  of  the  opinion  that  he  obtained  crepitus, 
accordingly  he  dressed  the  limb  with  the  straight  splint  for  six  weeks, 
and  at  the  end  of  that  time  found  half  an  inch  shortening.  The  speci- 
men afterwards  came  into  Prof.  Parker's  possession.  The  points  Prof. 
Parker  relies  on  to  show  that  this  was  a  fracture,  are :  1.  The  supposed 
crepitus.  2.  A  ridge  of  bone  along  the  inter-trochanteric  line,  termed 
the  'callus.'  3.  The  neck  of  the  bone  shortened  on  the  outer  side 
one-third  of  an  inch  more  than  on  the  inner  side,  this  being  accounted 
for  on  the  supposition  that  it  was  produced  by  the  position  the  limb 
was  allowed  to  retain.  4,  No  such  changes  are  to  be  found  in  the 
femur  of  the  opposite  side,  which  is  pronounced  healthy. 

"  These  specimens  were  procured  four  years  after  the  injury.  The 
capsule  is  entirely  gone,  and  there  is  nothing  to  show  positively  where 
it  was  inserted ;  a  line  is  pointed  out  about  three  lines  below  the  so- 
called  callus,  as  the  line  of  insertion  of  the  capsule.  On  examination 
of  the  interior  of  the  specimen,  there  is  nothing  to  indicate  the  line  of 
fracture  ;  no  callus,  such  as  is  shown  on  internal  examination  of  other 
fractures  of  long  bones. 

"  There  is  one  point  very  marked  on  the  inner  edge  of  the  compact 
structure  of  the  shaft;  it  is  what  Sir  Astley  Cooper  terms  a  "buttress 
of  bone"  shooting  up  from  the  body  into  the  neck  and  head,  evidently 
as  a  support  to  the  head  in  the  new  angle  which  it  has  assumed,  with 
respect  to  the  shaft.  This  buttress  is  formed  apparently  by  the  can- 
cellated structure  being  more  compact  than  in  other  points.  On  com- 
paring this  specimen  with  the  femur  of  the  well  limb,  a  very  marked 
difference  is  observable :  this  line  or  buttress  is  stronger,  better  deve- 
loped, and  is  evidently  for  the  purpose  of  giving  support  to  the  head 
of  the  bone  in  this  new  position. 

"  The  specimen  is  far  from  being  satisfactory.  If  this  rough  line 
extending  along  the  inter-trochanteric  line,  is  in  reality  the  line  of 
callus,  then  it  is  extremely  probable  that  the  fracture  was  partially 
extra- capsular.  For  if  the  capsule  extended  along  the  line  which 
runs  below  this  line  that  is  pointed  out  as  the  line  of  fracture,  then 
the  insertion  of  the  capsule  must  have  been  as  low  down  as  the  middle 
of  the  trochanter  minor,  an  anomaly  in  regard  to  insertion  of  the  cap- 
sule. If  this  really  was  the  line  of  insertion,  it  is  extremely  unfortunate 
that  the  capsule  was  not  left  to  show  where  it  was  inserted. 

"Again,  there  is  no  callus  on  the  inside  of  the  bone  corresponding 
to  this  so-called  external  callus,  but  throughout  the  whole  line  corre- 
sponding to  this  external  'callus'  the  cancellated  structure  is  perfect. 
If  it  should  be  admitted  that  crepitus  was  here  obtained,  a  point  which 
is  extremely  doubtful,  as  we  have  only  the  opinion  of  a  doctor  who 
practised  many  years  ago  in  the  small  town  of  Barnard,  Vt.,  a  town 
which  now  numbers  less  than  two  thousand  inhabitants — if  it  should 
be  admitted  on  such  authority  that  this  was  a  fracture — still,  it  is  by 
no  means  established  that  this  was  an  intracapsular  fracture,  for  this 
so-called  callus  extends  along  the  inter-trochanteric  line.    The  capsule 


366  FRACTURES  OF  THE  FEMUR. 

itself  is  gone,  so  that  it  cannot  be  shown  positively  where  it  was  in- 
serted, and  it  is  probable,  if  there  was  a  fracture,  it  was  partly  extra- 
capsular. 

"Again,  the  view  which  Prof.  Parker  takes  of  his  specimen  conflicts 
with  that  taken  by  Robert  W.  Smith,  of  Dublin,  on  fractures  of  this 
class,  in  his  work  already  quoted.  For  if  there  was  crepitus,  then 
there  must  have  been  motion  of  one  fragment  on  the  other;  and  if 
there  was  motion,  then  the  fracture  was  not  impacted ;  and  it  is  only 
this  latter  class  which,  Mr.  Smith  contends,  can  unite.  My  own  im- 
pression is  that  there  never  was  a  fracture  here  at  all.  I  think  this  is 
a  case  of  interstitial  absorption  of  the  neck  of  the  bone,  the  cause  of 
this  absorption  being  the  contusion  received  by  the  fall.  This  view  is 
sustained  by  analogy.  Sir  Astley  Cooper  says  this  is  common  in  old 
people.  'As  the  shell  becomes  thin,  ossific  matter  is  deposited  on  the 
upper  side  of  the  cervix,  opposite  the  edge  of  the  acetabulum,  and 
often  a  similar  portion  at  its  lower  part,  and  thus  the  strength  of  the 
bone  is  in  some  degree  preserved.  This  state  of  things  may  be  fre- 
quently seen  in  very  old  persons.'  '  When  the  absorption  of  the  neck 
proceeds  faster  than  the  deposit  on  the  surface,  the  bone  breaks  from 
the  slightest  cause;  and  this  deposit  wears  so  much  the  appearance  of 
a  united  fracture,  that  it  might  be  easily  mistaken  for  it  before  the  bone 
thus  alters.  We  sometimes  meet  with  a  remarkable  buttress  shooting 
up  from  the  shaft  of  the  bone  into  its  head,  giving  it  additional  sup- 
port to  that  which  it  receives  from  the  deposit  of  bone  on  its  external 
surfafce.' 

"Mr.  Liston  says:  'Gradual  shortening  of  the  lower  extremity  often 
ensues  upon  contusions  of  the  hip  in  persons  advanced  in  life,  in  con- 
sequence of  interstitial  absorption  of  the  neck  of  the  thigh-bone,  and 
alteration  of  the  angle  in  which  it  is  set  upon  the  shaft.  The  head  of 
the  bone  undergoes  a  change  in  form ;  it  becomes  flattened  and  ex- 
panded, and  the  cotyloid  cavity  is  made  to  correspond.  This  cause  of 
lameness  ought  to  be  kept  in  view.  The  risk  of  its  occurrence  ought 
to  be  explained  to  those  who  have  suffered  injury  of  the  hip,  and,  if 
possible,  it  must  be  prevented.' 

"Mr.  Gulliver,  in  the  JEdinburgh  Medical  and  Surgical  Journal,  No. 
128,  July,  1836,  et  seq.,  has  written  very  fully  on  this  subject  of  inter- 
stitial absorption,  and  has  adduced  cases  which  we  would  copy  if  our 
limits  would  allow.  He  shows  by  his  specimens  that  the  head  is  en- 
larged at  its  lower  part;  that  these  cases  may  occur  in  young  persons; 
that  it  is  not  disease  of  the  joint,  from  the  fact  that  there  is  no  anchy- 
losis; and  that  the  cartilages  are  not  involved.  The  cases  of  John 
Lynn,  J.  McGath,  and  J.  Fox,  etc.,  are  adduced,  and  the  specimens 
preserved  from  autopsies.  We  have  abundant  evidence  of  interstitial 
absorption  occurring  from  contusion  in  persons  like  this  maiden,  and 
Mr.  Gulliver  says  this  shortening  may  take  place  as  rapidly  as  in  five 
or  six  days.  Now,  Prof.  Parker's  specimen  corresponds  to  the  facts 
we  have  given.  1.  There  is  a  ridge  formed  along  the  lower  part  of 
the  neck,  as  Sir  Astley  Cooper  states  occurs  in  these  cases  of  interstitial 
absorption.  2.  There  is  the  buttress  of  bone  shooting  up  from  the 
shaft  into  the  head  as  a  means  of  support;  this  is  clearly  shown  by 


NECK,   WITHIN    THE    CAPSULE.  867 

comparing  the  two  specimens,  the  one  from  the  well  limb,  and  the  one 
from  the  contused  limb.  3.  There  was  a  contusion  sufficient  for  an 
exciting  cause.  4,  This  occurs  in  one  limb,  and  not  in  the  other,  as 
shown  in  the  case  of  J.  Fox,  reported  by  Gulliver,  where  one  limb  was 
in  every  respect  natural,  and  in  the  other  interstitial  absorption  had 
taken  place.  This,  we  believe,  is  the  case  in  Prof.  Parker's  specimen. 
If  this  specimen  is  in  reality  a  fracture,  it  was  most  probably  partly 
extra-capsular;  if  not,  it  was  a  case  of  interstitial  absorption,"^ 

Dr.  Alden  March,  the  distinguished  Professor  of  Surgery  in  Albany 
Medical  College,  has  permitted  me  to  examine  two  specimens  belonging 
to  his  collection,  which  he  regards  as  examples  of  bony  union  within 
the  capsule.  He  has,  however,  rendered  it  unnecessary  that  I  should 
describe  particularly  the  appearances  which  they  present,  by  having 
himself  given  an  account  of  them,  accompanied  with  drawings,  in  a 
paper  entitled  "Osseous  Union  of  Tntra-Capsular  Fracture  of  the  Neck 
of  the  Femur,"  published  in  the  Transactions  of  the  Medical  Society  of 
the  State  of  New  York,  for  the  year  1858.  The  account  of  the  first 
specimen  is  as  follows : — 

"Of  the  two  specimens  here  presented  for  examination,  as  examples 
of  intra-capsular  fracture  of  the  femur  united  by  bone,  the  smaller  one, 
numbered  884,  was  procured  in  London  some  years  siace,  and  at  that 
time  was  regarded  by  the  curator  of  the  old  London  Hospital  Museum 
as  a  good  specimen  of  fracture  and  bony  union  of  the  neck  of  the  femur 
within  the  capsular  ligament.  I  can  give  no  history  of  the  patient,  or 
subject,  from  whom  it  was  taken.  I  think  it  could  not  have  belonged 
to  an  old  person,  and  it  is  quite  clear  that  he  or  she,  as  the  case  may 
be,  lived  long  enough  after  the  occurrence  of  the  fracture  for  it  to 
become  thoroughly  reunited  by  bony  material. 

"  The  neck  of  the  bone  is  very  much  absorbed,  which  will  be  found 
to  be  the  case  in  almost  all  instances  of  intra-capsular  fracture,  whether 
united  by  bony  or  ligamentous  material.  This  specimen,  with  several 
others  of  various  kinds  of  organic  change,  was  submitted  to  the  exa- 
mination of  an  able  professor  of  surgery,  who  has  recently  devoted 
much  attention  to  the  study  of  fractures,  and  who  remarks  upon  it  as 
follows:  'Specimen  884  is  plainly  enough  a  fracture,  and  I  think  there 
can  be  no  doubt  that  on  one  side  of  the  neck  the  fracture  was  within 
the  capsule,  but  I  have  no  means  of  determining  whether  it  was  also 
within  the  capsule  on  the  opposite  side,  since  the  neck  is  almost  com- 
pletely absorbed.' 

"On  close  examination,"  continues  Dr.  March,  "it  will  be  found 
that  about  all  the  part  of  the  bone  that  can  be  called  neck  is  connected 
with  the  shaft,  and  that  the  fracture  appears  to  be  nearly  transverse, 
and  close  to  the  articulating,  or  cartilaginous  border  of  the  head.  It 
strikes  me  that  it  is  just  as  clearly  altogether  within  the  capsule  as  it 
is  a  fracture." 

In  defence  of  the  opinion  already  expressed  by  myself  in  relation  to 
this  specimen,  and  to  which  Dr.  March  has  seen  fit  to  refer  in  the  pas- 

1  This  specimen  is  probably  the  same  to  which  Prof.  Parker  has  made  allusion  in 
his  notes  to  the  fourth  American  edition  of  Samuel  Cooper's  First  Lines  of  Surgery,  at 
page  354  of  volume  second. 


368  FEACTURES    OF    THE    FEMUR. 

sage  above  quoted,  I  will  say,  that  the  almost  total  absence  of  the  neck 
posteriorly,  where,  in  the  natural  condition  of  the  parts,  quite  half  an 
inch  of  the  neck  belongs  outside. of  the  capsule,  renders  it  impossible, 
in  my  opinion,  to  determine  whether  the  fracture  was  not  in  part  with- 
out the  capsule.  This  remark  will  apply  to  all  similar  examples,  un- 
less, indeed,  the  capsule  itself  remains  to  indicate  precisely  where  this 
small  portion  of  the  neck  belongs ;  but  the  capsule  is  gone  from  this 
specimen,  and  the  neck  is  lost  posteriorly.  If  it  is  true,  then,  that  the 
line  of  fracture  can  be  shown  to  be  close  to  the  head  of  the  bone,  it  is 
equally  true  that  it  hugs  the  trochanter;  we  have  just  as  much  right, 
therefore,  to  interpret  its  proximity  to  the  trochanter  in  favor  of  an 
extra-capsular  fracture,  as  has  my  distinguished  friend  to  interpret  its 
proximity  to  the  head  in  favor  of  an  intra-capsular  fracture. 

Moreover,  this  specimen  has  never  been  sawn  open,  or  subjected  to 
the  test  of  boiling,  or  of  maceration,  nor  in  any  other  way  has  the 
most  important  question  of  ail  been  definitely  settled,  namely,  whether 
the  union  is  by  bony  or  by  fibrous  tissue. 

The  second  specimen  is  described  by  Dr.  March  much  more  at 
length,  rendering  it  necessary  that  our  own  account  of  it  should  be 
somewhat  condensed. 

Fred.  L.  fell  from  a  shed  when  ten  or  twelve  years  old,  and,  accord- 
ing to  the  testimony  of  respectable  citizens,  was  attended  by  a  sur- 
geon, and  treated,  as  they  think,  for  a  fractured  thigh  ;  but  it  does  not 
appear  probable  that  splints  were  used,  as  a  woman  was  known  to 
carry  him  up  and  down  stairs  on  her  shoulders  during  the  time  he  was 
under  the  surgeon's  care.  It  appears,  also,  that  "  immediately  after 
getting  about  he  was  just  about  as  lame,  as  much  of  a  cripple,  and  as 
much  distorted  in  his  figure  as  he  was  at  any  time  previous  to  his 
death,"  He  is  mentioned  by  one  of  the  witnesses  who  knew  him  for 
many  years  after,  as  a  "distorted  cripple."  Dr.  March  himself  had 
known  him  twenty-five  or  thirty  years,  and  describes  him  as  a  large 
framed  man,  with  a  "  peculiar"  gait,  "  a  kind  of  side  waddle,  one  limb 
appearing  to  be  two  or  three  inches  shorter  than  the  other,  and  with 
the  hip  of  the  shortened  side  greatly  projecting  laterally."  He  was 
about  58  years  of  age  when  he  died. 

More  or  less  of  the  skeleton  of  this  man  came  subsequently  into 
the  possession  of  Dr.  March,  and  he  describes  one  of  the  thigh-bones 
as  follows: — 

"  A  pretty  large  surface  at  its  upper  part  and  toward  the  trochanter 
major  is  a  little  flattened,  and  has  the  appearance  of  having  been  worn 
away,  deprived  of  its  cartilage,  and  becoming  eburnated,  or  presenting 
at  one  point  a  porcelaneous  polish."  This  change  Dr.  March  regards 
as  the  result  of  interstitial  and  progressive  absorption,  aided  by  attri- 
tion, and  as  having  occurred  at  an  advanced  period  of  life. 

On  the  anterior  superior  part  of  the  neck  is  a  ridge  of  bone,  to 
which  a  portion  of  the  capsular  ligament  remains  attached.  Most  of 
the  cartilaginous  covering  of  the  head  has  been  either  entirely  re- 
moved, or  very  much  thinned,  leaving  at  certain  points  a  polished  sur- 
face. That  part  occupied  originally  by  the  round  ligament  "  seems  to 
have  been  gettinor  into  a  state  of  ulceration."     The  whole  head  is  de- 


NECK,   WITHIN    THE    CAPSULE.  369 

pressed  and  turned  obliquely  backwards.  There  is  also  a  long  spine 
or  rib  of  bone  extending  upwards  and  inwards,  which  was  imbedded 
in  the  fibres  of  the  psoas  magnus  and  iliacus,  and  "seems  to  have  its 
attachment  at  its  base,  to  the  point  where  we  should  look  for  a  tro- 
chanter minor." 

At  first  Dr.  March  thought  that  the  shaft  of  the  opposite  femur  had 
also  been  broken  three  inches  below  the  trochanter  minor,  and  that 
it  had  united  with  some  slight  deformity.  He  also  found  the  ala  of 
the  pelvis  on  the  right  side  bent  inwards,  so  that  the  distance  from  the 
crest  to  the  centre  of  the  sacrum  was  three-fourths  of  an  inch  less 
than  on  the  opposite  side.  This,  too,  he  ascribed  at  first  to  the  original 
injury,  but  further  investigation  has  satisfied  him  that  it  was  due  to 
the  action  of  the  muscles,  and  that  the  opposite  limb  had  never  been 
broken. 

To  this  description,  condensed  from  the  paper  alluded  to,  I  need 
only  add,  that  the  whole  head  of  the  bone  is  very  much  flattened  and 
changed  in  shape,  and  that  there  is  scarcely  anything  which  can  be 
appropriately  called  a  neck.  The  bone  has  been  sawed  in  two,  but 
Dr.  March  does  not  pretend  that  the  bisection  furnishes  any  additional 
evidence  that  it  had  been  broken. 

My  objections  to  this  case  are  briefly  : — 

It  is  not  satisfactorily  made  out  that  there  was  ever  a  fracture,  either 
by  a  reference  to  the  original  history,  or  by  an  examination  of  the  bone. 
The  age  at  which  the  accident  occurred  (10  or  12  years),  is  presump- 
tive evidence  against  a  fracture  of  the  neck  of  the  femur  within  the 
capsule,  if  not  almost  conclusive,  unless  it  is  claimed  to  be  an  example 
of  epiphyseal  separation  with  a  bony  union,  a  supposition  which,  so 
far  as  I  can  learn,  no  surgeon  has  yet  ventured  to  make.  Dupuytren 
says  be  never  saw  a  fracture  of  the  neck  of  the  femur  in  a  child.  The 
youngest  I  have  seen  recorded  is  that  mentioned  by  Sabatier,  in  which 
case  the  boy  was  fifteen  years  old.'  Dupuj'tren  has  also  well  explained 
the  causes  of  this  infrequency  of  a  fracture  of  the  neck  of  the  femur 
in  early  life. 

On  the  other  hand,  the  age  at  which  the  accident  occurred  was  favor- 
able to  the  production  of  disease  of  the  hip-joint.  The  whole  history 
of  the  patient,  from  that  time  onwards,  especially  his  peculiar  "  wad- 
dle," seems  to  indicate  that  his  hip-joints  were  both  diseased.  The 
autopsy  shows  that  they  actually  were  diseased,  and  renders  it  quite 
probable  also  that  all  of  the  bones  of  his  body  were  in  an  unhealthy 
condition.  The  specimen  itself  is  in  nearly  all  respects  a  counterpart 
of  many  others  to  be  found  in  the  museums  of  this  and  other  coun- 
tries, and  which  are  now,  by  almost  unanimous  consent,  declared  to  be 
examples  of  chronic  rheumatic  arthritis. 

Dr.  Mutter  thinks  also  that  specimen  B,  71,  in  his  collection  of 
bones,  now  lying  in  the  Jefferson  Medical  College  at  Philadelphia,  is 
a  genuine  example.  It  is  a  cleaned  and  dried  specimen,  from  which 
the  capsule,  and  all  the  soft  parts,  have  been  removed.  The  neck 
is  very  nearly  absorbed,  and  the  trochanter  major  is  rotated  backwards, 

'  Dupuytren  on  Dis.  and  Injuries  of  Bones,  p.  187. 

24 


370  FRA.CTUEES    OF    THE    FEMUR. 

as  we  see  in  nearly  all  examples  of  interstitial  absorption,  so  that  it 
almost  touches  the  head.  The  interior  has  never  been  exposed,  to 
determine  the  line  of  the  supposed  fracture,  nor  is  there  anything 
upon  its  external  surface  by  which  this  point,  so  essential  to  the  ques- 
tion at  issue,  can  be  decided.  It  may  be  an  example  in  point,  but  the 
proof  is  not  before  us. 

Dr.  Charles  A.  Pope,  Professor  of  Surgery  in  the  St.  Louis  Univer- 
sity, Missouri,  informs  me  that  he  has  an  example  of  "  intra-capsular 
fracture  of  the  neck  of  the  femur,  with  concomitant  fracture  of  the 
acetabulum.  The  union  by  bone  is  perfect,  although  the  neck  is,  as 
it  were,  gone,  the  head  being  almost  squarely  set  on  the  shaft  of  the 
bone.  The  head  is  much  deformed,  being  an  enlarged  cone,  and  fitting 
into  a  similarly  shaped  acetabulum.  The  motions  of  the  joints  were 
well  preserved." 

I  have  never  seen  this  specimen,  and  I  am  therefore  unable  to  speak 
of  it  authoritatively,  but  I  confess  I  do  not  see  how  it  is  possible  to 
know  that  the  fracture  was  wholly  within  the  capsule  when  the  neck 
is  gone.  If  the  capsule  remains  attached  to  the  specimen,  it  may  aid 
in  the  elucidation  of  this  point;  but  it  does  not  appear  from  Dr.  Pope's 
communication  that  such  is  the  fact.  I  should  be  gratified  if  this  dis- 
tinguished surgeon  would  give  the  profession  a  more  complete  account 
of  the  case. 

From  various  sources,  including  several  private  letters,  I  have  been 
able.to  gather  a  few  of  the  particulars  relating  to  a  case  which  for  some 
time  attracted  the  attention  of  the  profession  in  this  country;  but  a  full 
account  of  which,  I  regret  to  say,  has  never  been  published.' 

Somewhere  about  the  year  1832,  Mrs.  William  Nelson,  of  Derby, 
Yt.,  fell,  and  was  slightly  lamed.  Dr.  M.  F.  Colby,  of  Stanstead,  Lower 
Canada,  being  consulted,  declared  that  she  had  broken  the  neck  of  the 
thigh-bone.  She  was  accordingly  placed  in  a  horizontal  position,  and 
an  extending  apparatus  applied.  This  treatment  was  continued  one 
month,  during  which  time  she  became  insane;  but  from  this  condition 
she  ultimately  recovered.  At  the  end  of  one  month  the  apparatus  was 
removed,  and  she  was  able  to  walk  after  her  recovery  without  much 
halt,  and  the  limb  did  not  seem  to  be  much  shortened. 

Subsequently  the  husband  of  Mrs.  Nelson  prosecuted  Dr.  Colby  for 
causing  insanity  through  unnecessary  confinement,  alleging  that  the 
bone  was  not  broken;  and,  as  evidence  that  it  was  not,  testimony  was 
presented  to  show  that  she  was  able  to  walk  a  few  steps  immediately 
after  the  injury  was  received;  that  she  could  draw  up  her  legs;  that 
she  rode,  sitting  upon  the  seat  of  a  wagon ;  that  the  extending  splint 
was  continued  only  four  weeks,  and  that,  although  it  was  loosened 
occasionally  by  the  friends,  the  limb  did  not  shorten ;  and,  finally,  that 
she  had  a  perfect,  or  nearly  perfect,  limb. 

The  case  remained  in  court  several  years,  until  both  parties  were 
nearly  ruined;  but  ten  years  after  the  accident  Mrs.  Nelson  died,  and 
both  femurs,  says  Dr.  Mussey,  were  secured  by  Dr.  Colby.     The  one 

'  Boston  Med.  and  Surg.  Journ.,  Jan.  26,  1842  ;  Amer.  Journ.  Med.  Sci.,  April,  1857, 
p.  310. 


NECK,   WITHIX    THE    CAPSULE.  371 

believed  to  have  been  broken  was  then  sent  to  several  of  our  larger 
cities,  and,  among  others,  it  was  examined  by  Hayward  and  one  of  the 
Warrens  in  Boston;  Dixi  Crosby,  of  Dartmouth;  Willard  Parker; 
one  of  the  Eogers  in  New  York;   and  Robert  Xelson,  of  Canada. 

Robert  Nelson  and  Rogers  still  denied  that  it  had  been  broken,  both 
of  these  surgeons  affirming  that  the  bone  was  perfect;  but,  on  the  part 
of  the  defence,  it  was  subsequently  charged  that  a  spurious  bone  had 
been  laid  before  these  latter  gentlemen.  Drs.  Warren'  and  Hayward 
thought  it  had  been  a  dislocation ;  Drs.  Parker  and  Crosby  believed  it  to 
have  been  a  fracture  within  the  capsule,  and  that  it  was  united  by  bone. 

Dr.  Mussey,  to  whom  the  specimen  has  been  described,  but  who  has 
never  seen  it  himself,  says  that  "the  bone  belonging  to  the  injured 
limb  had  a  ridge  across  the  neck,  while  the  head  was  so  far  depressed 
as  to  shorten  the  thigh-bone  three-sixteenths  of  an  inch." 

Dr.  Colby  finally  received  a  judgment  in  his  favor  for  one  cent  costs, 
and  a  bond,  signed  by  the  prosecuting  attorney,  to  the  effect  that  the 
bone,  which  was  now  in  the  possession  of  the  prosecutor,  should  be 
given  up  to  the  defendant,  and  remain  in  his  possession  during  a  period 
of  six  months,  in  order  that  he  might  show  it  to  the  public;  but  this 
part  of  the  contract  has  been  broken,  and  the  bone  seems  now  to  be 
lost  to  science. 

Whatever  may  be  our  opinion  as  to  the  probability  of  the  fracture 
in  this  case,  the  absurdity  and  cruelty  of  the  allegation  of  malpractice 
is  too  plain  to  admit  of  discussion  or  a  doubt  among  intelligent  medi- 
cal men.  If  Dr.  Colby  thought  there  was  a  fracture — and  he  certainly 
had  reasons  to  think  so — his  treatment  was  such  as  every  judicious 
surgeon  would  have  adopted,  and  for  not  adopting  which  he  might 
justly  have  been  held  responsible. 

I  have  in  my  cabinet  a  cast  which  I  made  nearly  twenty  years  since, 
from  a  femur  then  owned  by  Prof.  James  Webster,  of  Rochester,  late 
Professor  of  Anatomy  in  the  University  of  Buftalo,  and  which  he  be- 
lieved to  be  a  case  of  union  by  bone  after  a  fracture  within  the  capsule. 
The  patient  from  whom  this  specimen  was  obtained  was  a  female,  and 
had  been  seen  by  him  before  death.  Its  resemblance  to  the  specimen 
owned  by  Dr.  March,  and  purchased  by  him  in  London,  is  so  perfect, 
that  I  believed  it  to  he  the  same  until  Dr.  March  informed  me  that  it 
was  not.  It  is  almost  its  exact  counterpart,  however,  as  I  know  by 
a  comparison  of  the  specimen  with  my  own  cast  of  Prof.  Webster's. 
This  fact  will  render  it  unnecessarj^  that  I  should  state  my  objections 
to  it,  since  the  same  remarks  will  apply  to  it  as  to  Dr.  March's  specimen. 

I  have  also  in  my  own  cabinet  a  femur  of  no  inconsiderable  preten- 
sions, belonging  clearly  to  that  class  of  specimens  recognized  by  Robert 
Smith.  Its  neck  is  greatly  shortened,  and  this  surgeon  would  regard  it, 
I  think,  as  an  impacted  intra-capsular  fracture,  but  its  claim  would  be 
promptly  denied  by  Malgaigne,  on  account  of  the  absorption  and  dis- 
tortion of  its  neck.  Its  history  has  been  kindly  furnished  to  m.e  by 
Dr.  H.  H.  Bissell,  of  this  city. 

'  Dr.  Mussey  says  "  Dr.  Warren  decided  there  had  been  a  fracture  ;"  but  I  have  it 
upon  the  authority  of  Dr.  Colby  that  Dr.  Warren  had  called  it  a  dislocation,  or  that  a 
■witness  so  testified.     Perhaps  it  was  not  the  same  Warren. 


372 


FRACTUEES    OF    THE    FEMUR. 


About  the  year  1883  Mrs.  Wakelee,  of  Clarence,  Erie  County,  New 
York,  set.  6S,  who  was  then  very  low  with  tubercular  consumption, 
and  so  ill  as  to  be  scarcely  able  to  walk  across  the  floor,  tripped  upon 
the  carpet  and  fell,  striking  upon  her  left  side.  She  was  unable  to 
rise,  but  was  laid  upon  a  bed  by  her  son.  Dr.  Wakelee,  a  very  intelli- 
gent physician,  residing  in  the  same  house,  who  did  not  suspect  a 
fracture.  Dr.  Bissell  saw  her  on  the  following  day,  and  on  rotating 
the  limb  outwards,  he  says  that  he  discovered  a  crepitus.  His  exami- 
nation was  greatly  facilitated  by  her  extreme  emaciation. 

Mrs.  W.  was  placed  upon  a  double-inclined  plane,  with  apparatus 
for  extension,  &c.,  and  left  in  charge  of  Dr.  Wakelee.  On  the  fifth 
day  the  splint  was  removed,  and  from  this  time  no  dressings  of  any 
kind  were  applied.  The  reason  for  this  change  of  treatment  was,  that 
she  was  likely  to  live  but  a  few  days,  in  consequence  of  the  state  of 
her  lungs,  and  that  such  confinement  would  only  hasten  her  death. 
Contrary,  however,  to  all  expectation,  she  gradually  convalesced,  so 
that  after  two  or  three  years  she  could  walk  on  crutches,  her  toes  turn- 
ing out  and  her  limb  becoming  somewhat 
shortened.  Four  years  after  the  accident 
she  died,  and  Dr.  Bissell  obtained  from 
Dr.  Wakelee  the  specimen,  of  which  the 
accompanying  drawing  is  a  faithful  deli- 
neation. 

I  am  informed,  also,  that  there  are  two 
specimens  in  the  Boston  Museums,  but 
the  descriptions  which  I  have  received  of 
them  are  too  imperfect  to  allow  me  to 
speak  of  their  merits. 

Such  is  the  present  state  of  the  testi- 
mony upon  this  interesting  but  difficult 
subject.  In  it  all  we  think  we  see  enough 
to  warrant  a  belief  that  under  certain 
favorable  circumstances  bony  union  may 
occur,  but  not  enough  to  establish  it  be- 
yond all  doubt.  There  are  those  who  feel 
much  more  assured,  and  who  are  as  con- 
fident of  this  fact  as  that  the  shaft  of  the 
femur  will  unite  by  bone ;  we  do  not  ac- 
cuse them  of  credulity,  and  we  invoke  for 
ourselves  the  same  exercise  of  charity 
toward  our  scepticism.  We  have  never  yet  seen  a  specimen  which, 
upon  a  careful  examination,  proved  satisfactory;  but  unless  our  want 
of  conviction  can  be  shown  to  be  the  result  of  a  wilful  blindness,  we 
shall  demand  protection  against  the  assaults  and  insinuations  which 
have  so  frequently  fallen  upon  those  who  ventured  to  doubt  the 
authenticity  of  every  specimen  which  was  laid  before  them. 

I  repeat,  that  it  seems  to  me  probable,  that  under  certain  favorable 
circumstances  this  union  will  occur;  these  favorable  circumstances 
have  relation  to  several  conditions,  such  as  age,  health,  degree  of 
separation  of  the  fragments,  laceration  of  the  periosteum  and  capsule, 


Vertical   section   of  Mrs.    Wakelee's 
femur,  acetabulum  and  capsule. 


NECK,   WITHIN    THE    CAPSULE.  373 

treatment,  &c.  Eobert  Smith  thinks  it  is  not  likely  to  occur  unless 
the  fragments  are  impacted,  but  Sir  Astlej  Cooper,  as  we  have  already 
seen,  admitted  its  possibility  whenever  the  reflected  capsule  and  the 
periosteum  were  not  torn,  and  at  the  same  time  the  fragments  were 
not  displaced.  If  to  these  conditions  we  were  to  add  moderate  but 
not  extreme  age,  with  good  health,  we  can  see  no  sufficient  reason 
why,  under  judicious  treatment,  bony  union  might  not  occasionally 
be  expected.  But  such  a  combination  of  circumstances  is  probably 
exceedingly  rare ;  and,  what  is  more  unfortunate,  if  they  exist,  the 
fracture  is  not  likely  to  be  recognized,  and  the  surgeon  will  fail  to 
avail  himself  of  those  advantageous  coincidences  which  might,  if 
understood  and  properly  treated,  secure  a  bony  union.  Dupuytren 
says,  when  the  fragments  are  not  displaced  "  its  existence  may  be 
suspected,  but  cannot  be  positively  asserted."  There  will  not  be 
wanting,  however,  examples  in  which  surgeons  will  believe  or  affirm 
that  they  have  recognized  the  fracture  and  wrought  the  cure.  I  have 
heard  of  many  such  instances,  and  Mr.  Smith  has  referred  to  one, 
which  is  quite  pertinent,  as  having  been  reported  in  the  Gazette  des 
Hopitaux.  A  woman,  set.  G-i,  was  treated  for  an  intra-capsular  fracture 
of  the  neck  of  the  femur  at  one  of  the  hospitals  in  Paris,  and  "  at  the 
end  of  four  weeks  she  was  discharged  perfectly  cured,  and  without 
shortening."  We  fully  partake  of  Mr.  Smith's  surprise  at  the  impu- 
dence of  this  claim,  yet  we  do  not  see  in  it  much  greater  improbability 
than  in  Mr.  Swan's  case,  received  by  both  Mr.  Smith  and  Sir  Astley. 
himself,  where  the  neck  was  found  almost  wholly  united  by  bone  in 
five  weeks,  although  the  woman  was  80  years  old,  and  actually  dying 
while  the  process  was  going  on!  Says  Dupuytren,  "I  would  lay  it 
down  as  a  general  principle  that  all  fractures  of  the  neck  of  a  cylin- 
drical bone  should  be  kept  at  rest  twice  as  long  as  ordinary  fractures 
of  the  same  bone;  and  even  after  that  period  I  have  seen  displacement 
take  place.  The  term  may,  therefore,  be  lengthened  to  a  hundred 
days,  or  even  longer  in  aged  and  feeble  persons,  whose  powers  of  repa- 
ration are  much  deteriorated." 

It  is  not  the  purpose  of  the  writer  to  describe  particularly  all  of  the 
accidents  or  pathological  conditions  with  which  these  fractures  may 
be  confounded.  It  is  sufficient  to  allude  to  them,  and  to  leave  to  others 
the  labor  of  a  complete  historical  record ;  but  I  am  tempted  to  devote 
a  paragraph  to  what  has  been  variously  termed  "morbus  coxae  senilis" 
{Robert  Smith) ;  "  chronic  rheumatic  arthritis"  {Adams) ;  "  interstitial 
absorption  of  the  neck  of  the  thigh-bone"  {B.  Bell);  and  by  others 
"  interstitial  and  progressive  absorption,"  but  the  exact  nature  and 
cause  of  which  morbid  changes  are  not  yet  fully  understood.  Mr. 
Colles  does  not  think  this  partakes  of  the  nature  of  rheumatism.  I 
have  myself  a  specimen  of  what  has  been  more  generally  called 
chronic  rheumatic  arthritis,  occurring  in  the  knee-joint,  accompanied 
with  a  flattening  and  eburnation  of  the  articular  surfaces,  and  Gulliver 
has  shown  that  similar  changes  of  form  in  the  neck  of  the  bone  may 
occur  in  tolerably  young  persons. 

I  suspect  also  that  it  will  be  found  to  occur  under  a  greater  variety 


874 


FEACTURES    OF    THE    FEMUR. 


Fig.  111. 


of  circumstances,  and  to  present  a  greater  variety  of  forms  than  have 

yet  been  described;  and  we  shall  perhaps 
find  a  partial  explanation  of  this  diver- 
sity and  frequency  in  one  single  circum- 
stance, namely,  the  peculiar  anatomical 
structure  of  the  neck.  The  neck  of  the 
femur  stands  nearly  at  a  right  angle 
with  the  shaft,  or  at  an  angle  so  great 
as  that  the  weight  of  the  body,  even  in 
health,  has  the  effect  to  gradually  de- 
press the  head  below  the  top  of  the  tro- 
chanter major,  and  to  diminish  its  length. 
This  is  seen  constantly  in  the  striking 
change  of  form  which  occurs  between 
childhood  and  old  age.  Now,  if  from 
any  cause  whatever,  such  as  a  blow  upon 
the  trochanter  or  upon  the  foot,  the  neck 
or  head  are  made  to  suffer,  and  inflam- 
mation, or  perhaps  only  a  slight  degree 
of  increased  action  in  the  absorbents 
ensues,  resulting  in  an  equally  slight 
softening  of  the  bony  tissue,  these  pathological  circumstances  may  end, 
sooner  or  later,  in  a  striking  change  of  form  in  the  neck  or  head.  But 
it  is  pot  necessary  to  suppose  an  external  injury  to  explain  the  occur- 
rence of  this  inflammation,  and  consequent  softening  of  the  bone ;  a 
scrofulous,  or  rickety,  or  tuberculous  constitution  may  occasion  it,  and 

Fig.  112. 


Section  of  tlie  femar  of  an  adult. 


Chronic  rheumatic  arthritis.    (Miller.) 


we  see   no  reason  why  these  conditions  are  not  as  likely  to  lead  to  a 
change  of  form  here  as  in  the  bones  of  the  leg  or  of  the  spine.     A 


KECK,   TTITHIN    THE    CAPSULE.  875 

change  of  form  in  the  head  may  be  the  result  of  an  ulceration  of  the 
cartilage,  and  a  change  of  form  in  the  neck,  of  ulceration  of  the  neck. 
Among  other  causes,  also,  "chronic  rheumatic  arthritis"  may  operate 
in  a  large  proportion  of  those  examples  which  belong  to  advanced 
life.  One  case,  reported  by  Gulliver,  would  seem  to  show  that  a  de- 
formity may  occur  here  as  a  result  of  disease,  and  independently  of 
pressure,^  yet  it  is  plain,  from  the  direction  which  the  deviation  of  the 
head  and  neck  usually  takes,  that  pressure  performs  an  important  part 
in  the  causation. 

From  these  various  causes,  operating  in  these  diverse  ways,  we  shall 
have  the  different  deformities  enumerated  and  described  by  surgical 
writers.  The  head  flattened,  irregularly  spread  out,  depressed  and 
polished;  the  neck  shortened  and  irregularly  thickened  and  expanded; 
the  trochanter  major  rotated  outwards  and  drawn  upwards ;  sinuous 
chasms  traversing  the  neck,  produced  by  ulceration ;  and  finally, 
shortening  of  the  neck,  by  a  true  interstitial  absorption,  and  with 
little  or  no  increase  in  its  breadth,  the  trochanter  major  also  being 
I'otated  outwards.  It  would  be  strange,  moreover,  if  the  interior  of 
these  bones  did  not  present  some  changes  in  structure,  such  as  have 
been  frequently  observed,  namely — an  irregular  expansion  or  conden- 
sation of  the  cellular  tissue,  and  which  latter  might  easily  be  supposed 
b}^  one  who  was  inattentive  to  all  of  these  circumstances,  to  indicate 
the  line  of  an  imaginary  fracture. 

The  following  example  will  illustrate  the  incipient  stage  of  one  class 
of  these  cases,  namely — that  in  which  the  neck  is  not  only  shortened, 
but  its  surface  is  irregularly  seamed,  as  if  it  had  been  broken  and  im- 
perfectly united. 

Wm.  ClarksoQ,  £et.  43,  was  admitted  into  the  Toronto  Hospital,  C. 
W.,  May  5,  1858,  with  tubercular  consumption,  of  which  he  died  on 
the  2oth  of  the  same  month. 

He  had  been  under  the  care  of  Dr.  Scott,  and  it  having  been  noticed 
that  he  complained  of  his  right  hip,  at  the  time  of  admission,  an  autopsy 
was  made  on  the  25th,  at  which  I  was,  through  the  courtesy  of  the 
bouse  surgeon,  permitted  to  be  present. 

We  examined  both  hip-joints,  and  found  the  neck  of  the  right  femur 
shortened,  especially  in  its  posterior  aspect.  At  the  junction  of  the 
head  with  the  neck,  posteriorly,  and  extending  about  half  way  around, 
the  bone  was  carious,  and  so  far  absorbed  as  to  leave  a  sulcus  of  a  line 
or  two  in  depth,  and  of  about  the  same  width.  Adjacent  to  this,  also, 
the  bone  was  quite  soft,  yielding  under  the  slightest  pressure  of  the 
knife.  There  was  no  other  appearance  of  disease.  The  opposite 
femur  was  sound. 

The  hospital  record  furnished  the  following  account  of  his  case,  so  far 
as  the  injury  to  his  hip  was  concerned : — 

About  nine  months  before  admission,  then  laboring  under  the  ma- 
lady of  which  he  finall}^  died,  he  received  a  blow  upon  his  right  tro- 
chanter, ever  since  which  he  had  been  lame,  and  suffered  pain  in  the 
region  of  the  hip-joint.  The  pain  was  felt  especially  in  the  groin,  when 
the  trochanter  was  pressed  upon,  or  when  the  sole  of  his  foot  was  per- 

'  Gulliver,  Lond.  Med.-Chir.  Rev.,  vol.  xxxix.  p.  544. 


376  FRACTURES    OF    THE    FEMUR. 

cussed.  The  thigli  was  slightly  flexed;  the  toes  a  little  everted ;  and 
he  walked  with  some  halt. 

The  case  of  the  soldier,  Fox,  reported  by  Gulliver,  and  who  died  of 
tuberculosis,  presents  a  case  also  exactly  in  point,  but  illustrating  a 
later  stage,  or  the  completion  of  the  same  process. 

Of  the  precise  nature  of  the  changes  in  the  two  following  examples, 
I  cannot  be  certain,  since  they  have  not  been  determined  by  dissection. 
They  will  serve,  however,  to  illustrate  the  usual  history  and  progress 
of  a  considerable  number  of  cases.  They  certainly  were  not  examples 
of  fracture. 

Ephraim  Brown,  when  twelve  years  old,  fell  from  a  tree  and  struck 
upon  his  right  foot.  Dr.  Silas  Holmes,  of  Stonington,  Ct.,  was  called. 
Of  the  particular  symptoms  at  this  time,  I  have  only  learned  that  the 
leg  was  not  shortened.  The  doctor  laid  a  plaster  upon  his  hip,  and 
left  him  without  any  further  treatment.  In  three  days  he  was  able  to 
walk  on  crutches;  in  three  weeks  he  walked  without  crutches,  and  in 
four  months  was  at  work  as  usual.  There  was  at  this  time  no  shorten- 
ing or  deformity  of  any  kind. 

Mr.  Brown  subsequently  enlisted  as  a  soldier  in  the  war  of  the 
American  Revolution,  and  experienced  no  difficulty  in  this  hip  until 
after  a  severe  illness  which  followed  upon  an  unusual  exposure,  when 
he  was  about  thirty-five  years  old.  At  this  period  the  leg  began  to 
shorten,  but  the  shortening  was  unaccompanied  with  pain  or  soreness. 

He  consulted  me,  July  17,  1845,  at  which  time  he  was  eighty-three 
years'  old,  and  a  remarkably  strong  and  healthy -looking  man.  The 
shortening,  which  had  ceased  to  progress  some  years  before,  amounted 
at  this  time  to  two  and  a  half  inches. 

An  officer  in  the  United  States  army  addressed  to  me  the  following 
letter,  dated  Nov.  13,  1849  :— 

"My  mother-in-law,  Mrs.  S.,  of  D.,  some  three  years  since  fell  down 
a  flight  of  stairs,  striking  on  her  side  upon  a  stone,  injuring  the  hip- 
joint  severely;  but  upon  examination,  her  physician  declared  that 
there  was  neither  a  fracture  nor  a  dislocation,  and  said  that  she  would 
gradually  recover.  Something  like  one  year  since  the  injured  limb 
commenced  shortening,  so  that  she  can  now  barely  touch  her  toe  to 
the  floor  as  she  walks.  She  can  bear  but  little  weight  upon  it,  and 
is  compelled  to  use  a  crutch  or  a  cane  constantly.  So  much  time  has 
now  elapsed,  and  the  limb  is  so  little  better,  and  constantly  becoming 
shorter,  I  have  proposed  to  ask  your  opinion,"  &c. 

I  need  scarcely  say  that  I  had  no  hesitation  in  pronouncing  this  a 
case  of  chronic  inflammation  of  the  bone,  accompanied  with  softening 
and  gradual  change  of  form,  either  of  the  neck  or  head,  or  of  both. 

It  is  proper  that  I  should  state  briefly,  before  I  leave  this  subject, 
what  constitute  the  chief  difficulties  in  the  way  of  union  by  bone  within 
the  capsule. 

The  persons  to  whom  the  accident  occurs  are  generally  advanced  in 
life,  and  consequently  the  process  of  repair  is  feeble  and  slow. 

The  head  of  the  bone  receives  its  supply  of  blood  chiefly  through 
the  neck  and  reflected  capsule,  and  when  both  are  severed,  the  small 
amount  furnished  by  the  round  ligament  is  found  to  be  insufficient. 


NECK,   WITHIX    THE    CAPSULE. 


377 


When  the  fragments  are  once  displaced,  it  is  difficult,  as  I  have 
already  explained,  if  not  impossible,  to  i^eplace  them. 

The  direction  of  the  fracture  is  generally  such  that  the  ends  of  the 
fragments  do  not  properly  support  and  sustain  each  other  when  they 
are  in  apposition. 

The  fracture  is  at  a  point  where  the  most  powerful  muscles  in  the 
body,  acting  with  great  advantage,  tend  to  displace  the  broken  ends. 

Aged  persons,  who  are  chiefly  the  subjects  of  this  accident,  do  not 
bear  well  the  necessary  confinement,  and  especially  as  the  union  requires 
generally  a  longer  time  than  the  union  of  any  other  fracture ;  so  that 
a  persistence  in  the  attempt  to  confine  the  patient  the  requisite  time 
often  causes  death. 

Whether  the  absence  of  provisional  callus  as  a  boud  of  union,  and 
the  interposition  of  synovial  fluid  between  the  ends  of  the  fragments, 
constitute  additional  obstacles,  I  am  not  fully  prepared  to  say.  In  the 
opinion  of  many  surgeons  these  circumstances  constitute  very  serious, 
if  not  the  chief,  obstacles. 

It  remains  only  to  consider  what  is  the  usual  result  of  this  fracture. 

The  fragments,  more  or  less  displaced,  undergo  various  changes. 
The  acetabular  fragment  is  generally  rapidly  absorbed  as  far  as  the 
head,  and  occasionally  a  considerable  portion  of  this  latter  disappears 
also ;  while  the  trochanteric  fragment  appears  rather  as  if  it  had  been 


Fig.  113. 


Fis.  114. 


Fracture  of  cervix  femoris  Tvitliia  capsule. 
Unuaited.  Opposite  surfaces  irregularly  con- 
vex and  concave,  and  polished ;  moving  slightly 
npon  each  other.  (From  a  specimen  in  the  pos- 
session of  Dr.  Crosby.) 


Jlayo's  specimen.  United  by  ligament.  Patient 
lived  nine  months  after  the  accident.  The  trochanter 
minor  arrested  the  descent  of  the  head.  (From  Sir  A . 
Cooper.) 


flattened  out  by  pressure  and  friction,  it  having  gained  as  much  gene- 
rally in  thickness  as  it  has  lost  in  length.  To  this  observation,  how- 
ever, there  will  be  found  many  exceptions.   Sometimes  the  trochanteric 


378 


FRACTUEES    OF    THE    FEMUR. 


fragment  forms  an  open,  shallow  socket,  into  whicli  the  acetabular 
fragment  is  received;  or  its  extremity  may  be  irregularly  convex  and 
concave,  to  correspond  with  an  exactly  opposite  condition  of  the  ace- 
tabular fragment,  (Fig.  113.) 

Ordinarily  the  two  fragments  move  upon  each  other,  without  the 
intervention  of  any  substance ;  but  often  they  become  united,  more  or 
less  completely,  by  fibrous  bands  (Fig.  114),  which  bands  may  be 
short  or  long,  according  to  the  amount  of  motion  which  has  been  main- 
tained between  the  fragments  while  they  were  forming,  or  to  the  de- 
gree of  separation  which  exists. 

The  capsular  ligaments  are  usually  considerably  thickened  and  elon- 
gated in  certain  directions,  and  not  unfrequently  penetrated  by  spicule 
of  bone.  They  are  also  found  sometimes  attached  by  firm  bands  to 
the  acetabular  fragment. 

A  permanent  shortening,  either  with  or  without  eversion  of  the 
limb,  are  the  invariable  consequences  of  this  accident.  Indeed,  not  a 
few  succumb  rapidly  to  the  injury,  perishing  from  a  low,  irritative 
fever,  or  from  gradual  exhaustion,  within  a  month  or  two  from  the 
time  of  its  occurrence.  Says  Robert  Smith:  "Our  prognosis,  in  cases 
of  fracture  of  the  neck  of  the  femur,  must  always  be  unfavorable.  In 
many  instances  the  injury  soon  proves  fatal,  and  in  all  the  functions 
of  the  limb  are  forever  impaired;  no  matter  whether  the  fracture  has 
taken  place  within  or  external  to  the  capsule — whether  it  has  united 
by  ligament  or  bone — shortening  of  the  limb  and  lameness  are  the 
inevitable  results." 

Treatment. — In  case,  then,  of  a  complete  fracture  within  the  capsule, 
existing  without  laceration  of  the  reflected  capsule,  or  displacement  of 
the  fragments,  and  equally  in  case  of  a  fracture  at  the  same  point  with 
impaction,  the  treatment  ought  to  be  directed  to  the  retention  of  the 
bone  in  place,  by  suitable  mechanical  means,  for  a  length  of  time  suffi- 
cient to  insure  bony  union,  or  for  as  long  a  time  as  the  condition  of 
the  patient  will  warrant. 

The  means  which  are  best  calculated  to  fulfil  this  important  indica- 
tion are,  in  my  judgment,  complete  rest  in  the  horizontal  posture,  the 
limbs  being  secured  in  straight  splints  constructed  somewhat  after  the 
principle  of  Gibson's  improvement  of  Hagedorn's  apparatus ;  that  is, 

Fig.  115. 


Gibson's  modification  of  Hagedorn's  splint. 


the  sound  limb  being  first  secured  to  the  foot-board,  and  the  broken 
limb  subsequently  brought  down  to  the  same  point.  In  this  way  we 
may  dispense  with  the  perineal  band  as  a  means  of  counter-extension, 


NECK,   WITHIN    THE    CAPSULE. 


379 


whicli  is  so  painful,  indeed  insupportable  often,  when  the  fracture  is  at 
the  neck,  the  hip  of  the  broken  limb  being  prevented  from  descending 
by  the  lateral  pressure  of  the  two  long  splints.  This  apparatus  pos- 
sesses also  this  advantage,  namely,  that  it  presses  the  broken  fragments 
more  firmly  against  each  other,  and  thus  operates  to  prevent  their  dis- 
placement in  the  direction  of  the  axis  of  the  shaft. 

Fig.  116. 


Gibson's  splint  applied. 

In  treating  this  fracture,  supposing  no  displacement  to  exist,  no 
extension  beyond  that  which  is  necessary  to  insure  perfect  quiet  can 
be  proper,  inasmuch  as  the  fragments  are  not  overlapped;  and  they 
need  only  a  moderate  assistance  to  enable  them  to  maintain  their  posi- 
tion against  the  action  of  the  muscles.  j\[oreover,  if  the  fragments  are 
impacted,  violent  extension  would  disengage  them  and  render  their 
displacement  and  non-union  inevitable. 

Of  course  no  side  splints  are  necessary,  but  both  limbs  should  be 
secured  through  their  whole  length  to  the  long  lateral  splints,  and 
properly  supported  by  junks  and  pads. 

I  am  prepared  to  affirm,  from  my  own  experience,  that  more  patients 
will  endure  quietly  this  position  for  a  length  of  time  than  the  ilexed 
position,  whether  in  this  latter  the  patient  is  placed  upon  his  side  or 
upon  his  back. 

How  long  the  patient  will  submit  to  this,  or  to  any  other  mode  of 
securing  perfect  rest,  is  very  uncertain,  and  the  decision  of  this  ques- 
tion must  rest  with  the  individual  cases  and  the  good  sense  of  the 
surgeon.  Not  very  many  old  and  feeble  people  will  bear  such  con- 
finement many  days  without  presenting  such  palpable  signs  of  failure 
as  to  demand  their  complete  abandonment. 

A  mode  of  treatment  similar  to  this  was  adopted  in  Jones'  case,. and 
also  in  the  case  reported  by  Fawdington,  and  is  said  to  have  been  suc- 
cessful. In  Brulatour's  case  the  limb  was  kept  extended  two  months; 
in  Mussey's  second  case  Hartshorne's  straight  splint  for  extension 
remained  upon  the  limb  eighty-four  days ;  in  Bryant's  case  a  long 
splint  was  used  "some  weeks." 

It  is  true,  however,  that  other  plans  of  treatment  seem  to  have  been 
equally  successful.  In  the  case  reported  by  Adams  the  limb  was 
placed  over  a  double  inclined  plane,  made  of  pillows,  five  weeks;  and 
in  Mussey's  third  example  the  limb  remained  in  the  same  position  three 
months.  Chorley  laid  his  patient  upon  the  sound  side,  with  the  thighs 
flexed,  for  a  space  of  two  weeks,  and  then  turned  him  upon  his  back, 


880  FEACTUEES    OF    THE    FEMUE. 

still  keeping  tlie  thighs  flexed.    At  the  end  of  six  weeks  he  was  placed 
in  the  straight  position,  &g. 

But  in  a  majority  of  the  examples  reported,  the  existence  of  the 
fracture  was  eitlaer  not  suspected,  or  bony  union  was  not  anticipated 
or  desired,  consequently  no  treatment,  having  in  view  the  confinement 
of  the  broken  bone,  was  adopted.  Yet  the  success  was  as  great  as  that 
which  has  followed  from  either  of  the  other  plans.  Harris'  patient  was 
simply  laid  on  a  sofa.  Field's  patient,  who  broke  the  neck  of  both 
femurs  within  the  capsule  at  different  times,  was  in  each  case  left  with- 
out treatment,  except  that  she  laid  upon  her  bed.  Mussey  himself 
removed  all  dressings  from  Dr.  Dalton's  patient  on  the  eighteenth  day, 
and  placed  him  upon  his  feet,  and  Dr.  Wakelee  removed  the  apparatus 
from  his  mother  on  the  fifth  day. 

Nor  are  we  without  evidence  that  the  careful  and  judicious  applica- 
tion of  splints,  long  continued,  and  employed  under  the  most  favorable 
circumstances,  will  sometimes  fail.  The  two  following  cases  confirm 
these  remarks.  The  first  occurred  in  the  practice  of  Dr.  James  E. 
Wood,  of  the  city  of  New  York:  "  M.  J.,  a  young  lady,  get.  16  years; 
of  vigorous  constitution;  perfectly  free  from  any  constitutional  taint 
either  of  scrofula,  syphilis,  or  cancer;  was  caught  between  the  wheels 
of  two  carriages,  the  one  stationary,  the  other  in  motion.  The  blow 
was  received  directly  on  the  trochanter  major  of  the  right  side.  The 
symptoms  which  presented  themselves  showed  conclusively  that  there 
was  a  fracture.  There  was  shortening,  loss  of  voluntary  motion,  and 
evefsion;  by  placing  the  finger  on  the  trochanter  major,  and  the  thumb 
in  the  groin,  a  well-marked  crepitus  could  be  felt  on  extension  and 
rotation  being  made.  There  was  no  laceration  or  other  complication 
of  the  injury.  She  was  placed  on  Amesbury's  splint,  with  side  splints 
accurately  adjusted,  and  every  precaution  taken  to  insure  a  perfect 
union.  The  limb  was  kept  on  this  splint  without  being  disturbed  for 
six  weeks.  At  the  end  of  that  time,  it  was  taken  from  the  splint  and 
examined  with  care.  The  signs  of  fracture  still  remained ;  the  limb 
was  replaced  on  the  splint,  and  the  dressings  as  before;  everything 
was  attended  to  in  the  general  management  of  the  case  which  the 
doctor  thought  would  be  conducive  to  perfect  union.  The  patient  was 
kept  for  three  weeks  longer  on  the  splint,  which  was  then  removed. 
It  was  found  that  there  was  no  union.  Patient  lived  for  three  years, 
and  was  so  lame  that  she  was  always  obliged  to  use  a  crutch  in  walk- 
ing.    At  the  expiration  of  three  years  she  died  of  an  acute  disease. 

"  On  examination  of  the  cervix  femoris,  it  was  found  that  there  had 
been  a  transverse  fracture  of  the  bone  just  at  the  junction  of  the  head 
and  neck.  The  head  of  the  bone  was  still  attached  to  the  acetabulum 
by  the  ligamentum  teres.  The  process  of  absorption  had  been  going 
on,  and  the  head  of  the  bone  had  already  been  absorbed  below  the  level 
of  the  acetabulum,  and  what  remained  was  soft  and  spongy,  easily 
broken  with  the  handle  of  the  scalpel.  The  neck  of  the  bone  was 
rounded  off,  and  covered  with  a  fibrous  deposit.  This  was  not  a  case 
of  diastasis,  as  has  been  suggested  by  an  eminent  surgeon,  who  judged 
simply  from  the  age  of  the  patient.  She  was  full  sixteen  when  the 
accident  happened,  and  over  nineteen  when  she  died." 


NECK,   TVITHIX    THE    CAPSULE.  881 

Tbe  second  was  in  the  person  of  a  man,  ast.  25  years,  who  was  at 
the  time  of  the  accident  robust  and  in  good  health :  "  He  was  dancing 
at  his  sister's  wedding ;  while  cutting  a  pigeon  wing,  he  struck  the 
foot  upon  which  he  was  resting  from  under  him,  and  fell,  striking 
directly  upon  the  trochanter  major.  He  was  unable  to  rise  ;  a  carriage 
was  called  and  he  was  taken  directly  to  the  New  York  Hospital.  There 
he  came  under  the  charge  of  Dr.  J.  Kearney  Eodgers.  A  fracture  was 
immediately  diagnosticated,  and  for  a  few  days  he  was  kept  on  the 
double  inclined  plane.  The  straight  splint  was  then  used,  and  the 
dressings  kept  up  for  six  weeks;  at  the  end  of  that  time  they  were 
taken  off  and  the  limb  examined;  there  was  no  union.  The  limb 
was  continued  in  the  straight  splints  for  three  weeks  longer,  and  again 
examined — there  was  still  no  union.  The  patient  was  again  replaced 
in  the  straight  splint  for  two  weeks  longer,  but  no  union  occurred. 
At  the  end  of  three  months  from  his  admission  he  was  discharged;  he 
was  in  good  health,  but  so  lame  that  he  was  obliged  to  use  two  crutches 
in  walking.  After  his  discharge  the  patient  became  very  intemperate; 
and,  in  the  course  of  a  few  weeks  he  applied  for  admission  to  Bellevue 
Hospital.  He  was  much  debilitated,  and  had  an  exhausting  diarrhoea. 
Shortly  after  his  admission,  an  immense  abscess  formed  over  the  joint, 
which  discharged  profusely.  The  man  died  shortly  after  from  exhaus- 
tion, and  the  specimen  came  into  Dr.  Van  Buren's  hands,  the  patient 
having  been  in  his  service.  Dr.  Van  Buren  was  aware  of  the  patient's 
previous  history,  the  treatment,  etc.,  at  the  New  York  Hospital,  and  a 
careful  examination  was  made. 

"The  capsular  ligament  was  destroyed  entirely  by  the  suppurative 
process;  there  was  a  formation  of  callus  upon  the  trochanter  major; 
the  ligamentum  teres  was  entirely  absorbed;  the  head  of  the  bone  was 
spongy,  as  if  worm  eaten ;  the  direction  of  the  fracture  was  oblique, 
commencing  just  at  the  articulating  surface  of  the  head  and  ending 
just  within  the  capsule ;  the  upper  end  of  the  shaft  of  the  bone  showed 
this  same  appearance  that  was  marked  in  the  head.  These  points  are 
beautifully  shown  in  the  specimen  at  the  present  time.  The  opinion 
of  Charles  E.  Isaacs,  M.  D.,  the  able  Demonstrator  of  Anatomy  of  the 
University  Medical  College,  is,  that  this  fracture  was  entirely  within 
the  capsule.'"  The  bone  may  be  seen  in  the  museum  of  Prof.  AVm. 
H.  Van  Buren,  of  the  University  Medical  College,  New  York. 

Such  equal  results  from  opposite  plans,  and  unequal  results  from 
similar  plans  of  treatment,  are  not  calculated  to  increase  our  faith  in 
the  testimony  which  most  of  the  foregoing  examples  are  supposed  to 
furnish  of  the  possibility  of  bony  union.  On  the  contrary,  they  can- 
not fail  to  suggest  a  doubt  as  to  whether  some  of  them,  at  least,  were 
not  inaccurtitely  diagnosticated. 

But  admitting  that  they  were  not,  the  testimony  which  they  furnish 
in  relation  to  treatment  is  too  inconclusive  to  be  made  available  for 
instruction,  and  we  are  still  at  libert}^  to  adopt  that  which  seems  most 
rational,  without  reference  to  the  experience  of  others. 

The  reasons  why  I  would  prefer  Hagedorn's  plan,  have  already  been 

'  Jolinson,  op.  cit.  pp.  13-15. 


882 


FRACTUEES    OF    THE    FEMUR. 


stated  in  part,  to  which  I  will  now  add,  that  if  an  error  should  occur 
in  the  diagnosis — if  it  should  prove  finally  to  have  been  a  fracture 
without  the  capsule,  then  this  treatment  would  be  correct,  and  no  in- 
jury would  come  to  the  patient  from  the  error  in  diagnosis;  but  if  we 
adopt  Sir  Astley  Cooper's  suggestion,  namely,  to  get  the  patient  upon 
crutches  as  soon  as  possible,  perhaps  as  soon  as  fourteen  days,  an  error 
in  diagnosis  might  be  followed  by  the  most  disastrous  consequences. 

I  ought  to  add,  that  if  this  plan  for  any  reason  is  found  inconvenient 
or  inapplicable,  nothing  which  I  have  seen  will  prove  so  comfortable 
and  available  an  alternative  as  the  fracture  bed,  invented  by  Dr.  Daniels, 
of  New  York. 


(b.)  Neck  of  the  Femur  without  the  Capsule. 

Causes. — Like  fractures  within  the  capsule,  these  also  occur  most 
frequently  in  advanced  life;  age  may  therefore  be  regarded  as  the 
grand  predisposing  cause. 

As  to  the  immediate  causes,  we  have  already  mentioned  in  the  pre- 
ceding section  that  fractures  without  the  capsule  seem  to  be  the  result 
generall}^  of  falls  or  of  blows  received  directly  upon  the  trochanter ; 
occasionally,  also,  they  are  produced  by  falls  upon  the  feet  or  upon 
the  knees. 

Pathology. — These  fractures  may  occur  at  any  point  external  to  the 
capsule,  but  generally  the  line  of  fracture  is  at  the  base,  corresponding 
VQYy  nearly  with  the  anterior  and  posterior  inter-trochanteric  crests. 
Almost  invariably  the  acetabular  penetrates  the  trochanteric  fragment 
in  such  a  manner  as  to  split  the  latter  into  two  or  more  pieces.  The 
direction  of  the  lesions  in  the  outer  fragments  preserves  also  a  remark- 


Fig.  117. 


Fig.  118. 


Fig.  119. 


Impacted,  extra-capsular  fractures.  (R.  Smith,  and  Erichsen.) 

able  uniformity;  the  trochanter  major  being  usually  divided  from  near 
the  centre  of  its  summit,  obliquely  downwards  and  forwards  toward  its 
base,  and  the  line  of  fracture  terminating  a  little  short  of  the  trochanter 


NECK,   WITHOUT    THE    CAPSULE.  883 

minor,  or  penetrating  beneath  its  base ;  while  one  or  two  lines  of  frac- 
ture usually  traverse  the  trochanter  major  horizontally. 

In  an  examination  of  more  than  twenty  specimens,  I  have  noticed 
but  two  or  three  exceptions  to  the  general  rules  above  stated. 

In  Dr.  Mutter's  collection,  specimen  marked  B  115  is  not  accompa- 
nied with  either  impaction  or  splitting  of  the  trochanteric  fragment; 
but  the  neck  having  been  broken  close  to  the  inter-trochanterio  lines, 
has,  apparently,  slid  down  upon  the  shaft  about  one  inch,  at  which 
point  it  is  firmly  united  by  bone. 

Dr.  Neill  has  also  a  specimen  of  fracture  at  the  same  point,  but  with- 
out union  of  any  kind,  in  which  no  traces  remain  of  a  fracture  of  the 
trochanters.  The  acetabular  fragment  has  moved  up  and  down  upon 
the  trochanteric  until  it  has  worn  for  itself  a  shallow  socket  three 
inches  and  a  half  long ;  the  approximated  surfaces  being  smooth  and 
polished  like  ivory. 

The  trochanter  major  is  usually  turned  backwards,  the  shaft  of  the 
femur  being  rotated  in  this  direction,  the  same  as  is  usually  observed 
in  other  fractures  of  the  neck  of  the  femur.  I  have  seen  one  exception 
to  this  general  rule  in  a  specimen  belonging  to  Dr.  Mutter  (No.  29); 
the  trochanter  in  this  instance  is  turned  forwards,  so  that  the  neck  is 
shorter  in  front  than  behind. 

The  upper  fragments  of  the  trochanter  major,  whenever  the  lines 
of. fracture  are  transverse,  are  generally  inclined  inwards  toward  the 
neck,  as  if  displaced  in  this  direction  by  the  force  of  the  blow,  or 
perhaps  by  the  resistance  offered  by  certain  muscles  and  ligamentous 
bands  which  find  an  insertion  upon  its  summit. 

The  neck  is  found,  in  most  cases,  standing  inwards  at  nearly  a  right 
angle  with  the  shaft,  the  head  being  much  more  depressed  than  the 
outer  extremity  of  the  neck,  in  consequence  of  which  the  lower  mar- 
gin of  its  broken  extremity  is  driven  much  deeper  into  the  trochanteric 
fragment  than  is  the  upper  margin. 

Malgaigne  believes  that  impaction  with  consequent  fracture  of  the 
trochanters,  is  never  absent  in  true  extra-capsular  fractures,  unless  it 
be  in  that  very  unusual  variety  in  which  the  trochanter  forms  a  part 
of  the  inner  fragment  (fractures  through  the  trochanter  major  and 
base  of  the  neck).  Eobert  Smith  entertains  the  same  opinion,  although 
Malgaigne  does  not  seem  to  have  so  understood  him.  I  cannot  agree, 
however,  with  either  of  these  gentlemen  that  the  rule  is  so  invariable, 
since  I  am  confident  that  no  such  splitting  has  occurred  in  either  of 
the  two  specimens  to  which  I  have  referred  as  belonging  respectively 
to  Drs.  Miitter  and  Neill.  It  is  true  these  are  both  old  fractures,  and 
to  some  extent  the  signs  of  fracture  may  have  become  obliterated,  but 
in  Miitter's'  specimen  an  abundant  callus  indicates  plainly  enough 
where  the  shaft  separated  from  the  neck,  while  the  trochanter  major 
is  smooth  as  in  its  normal  condition,  nor  does  its  summit  incline  either 
way  from  its  usual  position.  Neill's  specimen,  though  less  satisfactory, 
does  not  fail  to  convince  me  that  neither  impaction  nor  splitting  of  the 
trochanters  ever  occurred. 

It  is  certain,  however,  that  impaction  and  comminution  of  the  outer 


384  FRACTURES    OF    THE-FEMUR. 

fragment  are  very  constant,  and  that,  whether  the  fracture  is  produced 
by  a  fall  upon  the  feet  or  upon  the  trochanter  major.  But  the  impac- 
tion does  not  necessarily  continue;  sometimes,  indeed,  it  does,  and 
the  position  of  the  limb,  whatever  it  may  be  at  the  moment,  remains 
unalterably  fixed  ;  either  very  little  or  considerably  shortened,  accord- 
ing to  the  degree  of  impaction ;  rotated  outwards  or  inwards,  or  in 
neither  direction,  perhaps,  according  to  the  direction  of  the  force 
and  of  the  fracture.  In  other  cases,  owing  to  the  extreme  comminu- 
tion, and  to  the  wide  separation  of  the  trochanteric  fragments,  or  to 
the  contraction  of  the  muscles  inserted  into  the  top  of  the  femur,  or 
to  the  weight  of  the  body  in  attempts  to  walk,  or  to  injudicious  hand- 
ling on  the  part  of  the  surgeon,  such  as  forcible  rotation,  by  which 
the  neck  is  made  to  act  as  a  lever,  and  to  actually  pry  the  fragments 
apart,  or  to  violent  extension,  by  which  the  impaction  is  overcome — 
owing  to  some  one  or  several  of  these  causes  it  often  happens  that  the 
fragments  separate,  and  the  leg  becomes  immediately  more  shortened, 
movable,  and  more  inclined  to  rotate  outwards. 

Symptoms. — The  symptoms  which  indicate  a  fracture  of  the  neck 
of  the  femur  without  the  capsule,  are  pain,  mobility,  crepitus,  short- 
ening and  eversion  of  the  limb.  The  trochanter  major  is  not  as  pro- 
minent as  upon  the  opposite  side,  and  it  I'otates  upon  a  shorter  axis. 
There  are  also  several  other  signs  to  which  I  shall  refer  when  consi- 
dering the  differential  diagnosis. 

The  pain  and  tenderness,  accompanied  sometimes  with  swelling  and 
discoloration,  are  situated  chiefly  in  front  of  the  neck  of  the  bone. 

Mobility  exists  in  a  majority  of  cases,  even  when  the  fragments  are 
impacted;  that  is,  the  limb  can  be  moved  pretty  easily  in  any  direction 
by  the  surgeon,  but  not  without  producing  pain  or  provoking  muscular 
spasms,  yet  the  patient  himself  is  unable  to  move  the  limb  by  his  own 
volition,  or  he  can  only  move  it  slightly. 

Crepitus  is  present  whenever  there  exists  a  moderate  but  not  com- 
plete impaction.  It  is  also  present  generally  when,  the  trochanteric 
fragment  having  been  extensively  comminuted  and  loosened,  the 
impaction  becomes  excessive;  and  it  is  only  absent  when  the  impaction 
is  such  that  the  fragments  are  completely  and  firmly  locked  into  each 
other. 

A  shortening  is  inevitable,  at  least  in  all  cases  accompanied  with 
either  temporary  or  permanent  impaction,  and  we  have  seen  that  one 
of  these  conditions  seldom  fails.  According  to  Sir  Astley  Cooper  the 
shortening  varies  from  half  an  inch  to  three-quarters  of  an  inch,  but 
Robert  Smith  has  established  the  following  distinction.  When  the 
fracture  is  extra-capsular  and  impacted,  that  is,  when  it  remains  im- 
pacted, the  shortening  is  only  moderate,  varying  from-one  quarter  of 
an  inch  to  one  inch  and  a  half;  in  fourteen  cases  measured  by  him 
the  average  was  a  fraction  over  three-quarters  of  an  inch ;  but  when 
it  does  not  remain  impacted  it  ranges  from  one  inch  to  two  inches  and 
a  half;  indeed,  Mr.  Smith  mentions  one  example  in  which  the  shortening 
reached  four  inches,  and  forty-two  cases  gave  an  average  shortening 
of  something  more  than  one  inch  and  a  quarter. 


XECK    OF    THE    FEMUE. 


385 


E version  of  the  toes  is  very  constant;  but  in  a  few  instances  upon 
record  the  toes  have  been  found  turned  in,  or 
even  directed  forwards.  In  the  specimen  referred 
to  as  being  found  in  Dr.  Mutter's  collection,  with 
an  inward  or  forward  rotation  of  the  trochanter 
major,  the  same  relative  position  of  the  whole 
limb  must  have  existed. 

The  trochanter  major  usually  seems  depressed 
or  driven  in,  and,  when  the  two  main  frag- 
ments are  completely  separated,  if  the  limb  is 
rotated,  the  trochanter  will  be  found  to  turn 
almost  upon  its  own  axis,  or  upon  a  very  short 
radius. 

In  enumerating  the  signs  of  extra-capsular 
fracture,  it  will  be  seen  that  I  have,  with  only 
slight  variations,  repeated  the  signs  of  a  fracture 
within  the  capsule.  It  will  become  necessary, 
therefore,  to  indicate,  as  far  as  possible,  a  differen- 
tial diagnosis.  And  without  pretending  that  all 
of  the  differential  signs  which  I  shall  enumerate 
are  thoroughly  established,  or  that  in  every  case, 
even  after  a  careful  grouping  of  all  the  symp- 
toms, a  satisfactory  diagnosis  can  be  made  out,  I 
shall  state  briefly  my  own  conclusions,  or,  rather, 
what  seem  to  me  to  be  the  probable  facts. 


Fracture  of  tlie  neck  of  the 
femur.     (Fergusson.) 


Signs  of  a  feactcbe  withi>"  the  capsule.     Sigxs  of  a  feactube  without  the  capsule. 


Produced  by  slight  violence. 
A  fall  upon  the  foot  or  knee,  or  a  trip 
upon  the  carpet,  ikc. 

Generally  over  fifty  years  of  age. 
More  frequent  in  females. 

Pain,  tenderness  and  swelling  less,  and 
deeper. 


(The  two  following  measurements  to  be 
made  from  the  anterior  superior  spinous 
process  of  the  ilium  to  the  inner  condyle 
of  the  femur.) 

Shortening  at  first  less  than  in  extra- 
capsular fractures,  often  not  any. 

Shortening  after  a  few  days  or  weeks 
greater  than  in  extra-capsular  fractures  ; 
sometimes  this  takes  place  suddenly,  as 
when  the  limb  is  moved,  or  the  patient 
steps  upon  it. 

Measuring  from  the  top  of  the  trochanter 
to  the  inner  condyle  or  to  the  malleolus 
internus  the  femur  is  not  shortened. 

More  mobility  of  limb,  at  joint. 
Trochanter  major  moves  upon  a  longer 
radius. 

25 


Produced  by  greater  violence. 
A  fall  upon  the  trochanter  major. 

Often  under  fifty  years  of  age. 

Relative  frequency  in  males  or  females 
not  established. 

Pain,  swelling,  and  tenderness  greater 
and  more  superficial.  It  is  especially  pain- 
ful to  press  upon  and  around  the  trochan- 
ter. 


Shortening  at  first  greater,  almost  always 
some. 

Shortening  after  a  few  days  or  weeks 
less  than  in  intra-capsular  fractures.  That 
is,  the  amount  of  shortening  changes  but 
little,  if  at  all ;  if  the  impaction  continues, 
not  at  all ;  if  it  does  not  continue  it  may 
shorten  more. 

Measuring  from  the  top  of  the  trochanter 
to  the  inner  condyle  or  to  the  malleolus 
internus  the  femur  may  be  found  a  little 
shortened. 

Less  mobility. 

Trochanter  major  moves  upon  a  shorter 
radius. 


386 


FEACTUEES    OF    THE    FEMUE. 


Signs  of  a  fracture  within  the  capsule. — 

( Contiyiiied. ) 

If  the  patient  recovers  the  use  of  the 
limb,  not  i-estored  under  three  or  four 
months. 

No  enlargement  or  apparent  expansion 
of  the  trochanter  major,  after  recovery, 
from  deposit  of  bony  callus. 

Progressive  wasting  of  the  limb  for  many 
months  after  recovery. 

Excessive  halting,  accompanied  with 
a  peculiar  motion  of  the  pelvis,  such  as  is 
exhibited  in  persons  who  walk  with  an 
artificial  limb. 


Signs  of  a  fracture  without  the  capsule. — 

(Continued.) 

If  the  patient  recovers  the  use  of  the 
limb,  restored  in  six  or  eight  weeks. 

Enlargement  or  irregular  expansion  of 
trochanter,  which  may  be  felt  sometimes 
distinctly  through  the  skin  and  muscles. 

The  limb  preserving  its  natural  strength 
and  size. 

Slight  halt,  motions  of  hip  natural. 


Prognosis. - 
Fig.  121. 


Fracture  of  neck  without 
the  capsule.     (Erichsen.) 


In  attempting  to  establish  the  clifterential  diagnosis  we 
have  necessarily  been  led  to  consider  most  of 
the  essential  points  of  prognosis,  A^ery  little, 
therefore,  remains  to  be  said  upon  this  subject. 

Union  generally  occurs  as  rapidly  in  this  frac- 
ture as  in  fractures  of  the  shaft,  and,  perhaps, 
even  sometimes  more  promptly,  owing  to  the 
existence  of  impaction. 

But  whether  it  occurs  promptly  or  slowly,  or, 
indeed,  if  it  does  not  occur  at  all,  a  remarkable 
deposit  of  ossific  matter  almost  invariably  takes 
place  along  the  inter-trochanteric  lines,  where 
the  bone  has  separated  from  the  shaft,  and  also, 
not  unfrequently,  along  the  lines  of  the  other 
fractures  of  the  trochanter. 

This  deposit  is  no  less  remarkable  for  its 
abundance  than  for  its  irregularity,  long  spines 
of  bone  often  rising  up  toward  the  pelvis  and 
forming  a  kind  of  knobby  or  spiculated  crown, 
within  which  the  acetabular  fragment  reposes. 


Fig.  122. 


Fig.  123. 


Extra-capsular  fractures.     Union  with  excess  of  callus.     (R.  Smith.) 


:n"eck,  without  the  capsule. 


387 


In  a  few  instaoces  these  osteophites  have  Fig-  124. 

reached  even  to  the  bones  of  the  pelvis,  and 
formed  powerful  abutments  which  seemed 
to  prevent  any  farther  displacement  of  the 
limb  in  this  direction,  and,  by  some  writers, 
they  have  been  supposed  thus  to  fulfil  a 
positive  design.  A  sufficient  explanation 
of  their  existence,  however,  we  think  can 
be  found  in  the  fact  that  they  proceed  en- 
tirely from  the  trochanteric  fragment,  whose 
extensive  comminution  and  great  vascu- 
larity would  naturally  lead  to  such  results. 
The  same,  but  in  a  less  degree,  has  already 
been  noticed  as  occurring  in  impacted 
fractures  at  the  anatomical  neck  of  the 
humerus,  where  certainly  such  bony  abutmeots  could  not  serve  any 
useful  purpose. 

Treatment. — The  same  principles  of  treatment  are  applicable  here  as 
in  fractures  of  the  neck  within  the  capsule ;  by  which  I  mean  to  say 
that,  as  in  all  of  those  examples  of  fracture  within  the  capsule  where 
the  relation  of  the  fragments  is  such  as  to  warrant  a  hope  that  a  bony 
union  may  be  consummated,  namely,  where  the  fragments  are  not  dis- 
placed or  are  impacted,  the  straight  splint,  with  only  moderate  exten- 
sion, constitutes  the  most  rational  mode  of  treatment;  so  also  in  this 
fracture,  whenever  the  fragments  are  impacted  and  remain  impacted, 
a  straight  splint,  employed  only  as  a  retentive  apparatus,  is  the  most 
suitable.  It  is  only  by  employing  this  plan  of  treatment,  which  no 
one  has  yet  shown  to  be  inapplicable  to  either  of  these  two  varieties 
of  accidents — I  do  not  speak  of  the  opinions  which  men  may  have 
entertained,  but  of  the  practical  testimony — it  is  only,  I  say,  by  em- 
ploying this  uniform  plan  of  treatment  in  both  cases  that  those 
serious  misfortunes  to  the  patient  can  be  avoided  which  would 
necessarily  continue  to  occur  if  Sir  Astley  Cooper's  advice  was  fol- 
lowed, namely,  to  allow  the  patient  in  the  one  case  to  dispense  with 
splints  wholly,  and  to  get  upon  his  crutches  as  soon  as  the  condition 
of  his  limb  and  of  his  body  will  permit,  when  it  is  certain  that  in  the 
other  case  some  retentive  apparatus  is  generally  necessary.  This 
conclusion  is  based  upon  the  admitted  difficulty  of  diagnosis.  If,  as  is 
well  understood,  the  diagnosis  between  these  two  varieties  of  fracture 
can  seldom  be  made  out  satisfactorily  during  the  life  of  the  patient, 
then  how  shall  we  know  in  any  given  case  which  of  the  two  plans  to 
adopt.  If  we  act  upon  the  supposition  that  it  is  within  the  capsule, 
adopting  Sir  Astley  Cooper's  method,  and  it  proves  to  have  been  a  frac- 
ture without  the  capsule,  we  have,  I  fear,  done  irreparable  injury  to  our 
patient.  It  is  precisely  here  that  this  distinguished  surgeon  committed 
his  great  error,  not  in  denying  that  certain  specimens  were  fractures 
of  the  neck  of  the  femur  within  the  capsule  united  by  bone,  nor  in 
constantly  urging  upon  his  contemporaries  the  improbability  of  such 
an  event,  but  in  that  while  he  admitted  its  possibility,  he  chose  to 
recommend  a  plan  of  treatment  which  was  unlikely  to  insure  such  a 


888 


FRACTURES    OF    THE    FEMUR. 


union,  and  which,  in  the  uncertainty  if  not  impossibility  of  diagnosis, 
was  liable,  upon  his  supposed  authority,  to  be  adopted  in  many  cases 
of  extra-capsular  fractures. 

Again,  if  the  fracture  be  extra-capsular  and  not  impacted,  or  the 
impaction  has  been,  for  any  cause,  overcome;  or,  if  the  fracture  be 
intra-capsular  and  not  impacted,  or  if  the  capsule  is  lacerated  and  the 
fragments  are  in  consequence  displaced;  then  again  no  injury  need 
result  from  the  treatment,  if  we  adopt  the  straight  splint  with  mode- 
rate extension,  such  as  may  be  obtained  from  the  use  of  Hagedorn's 
splint  modified  by  Gibson.  That  it  is  not  impacted  we  may  know 
often,  or  generally,  by  the  amount  of  displacement,  although  we  may 
not  easily  decide  whether  the  fracture  is  within  or  without  the  capsule. 
JSTow  the  amount  of  shortening  will  determine,  properly  enough,  the 
amount  of  extension  to  be  employed.  In  either  case  we  shall  not 
employ,  because  the  patient  will  not  permit,  as  much  extension  as  in 
fractures  of  the  shaft;  and  while  in  the  one  case  we  shall  only  gain  a 
shorter  and  firmer  ligamentous  union,  in  the  other  we  shall  insure  a 
better  and  more  speedy  bony  union. 

Fig.  125. 


Miller's  splint  for  extra-capsular  fractures.     (From  Miller.) 


If  any  surgeon,  acting  upon  the  suggestions  here  made,  shall  con- 
fine a  feeble  or  an  aged  person  in  the  horizontal  posture,  and  in  a 
straight  splint  until  the  powers  of  nature  have  become  exhausted,  and 
death  ensues,  as  our  readers  have  already  been  admonished  may  happen, 
we  are  not  to  be  held  responsible  for  his  want  of  judgment  or  of  skill. 
We  have  advised  this  plan  of  treatment  only  for  so  long  a  period  as  the 
condition  of  the  patient  renders  it  entirely  safe.  No  doubt,  then,  in  a 
large  number  of  cases  it  will  have  to  be  abandoned  very  early,  and  in 
not  an  inconsiderable  proportion  all  constraint  will  be  plainly  inadmis- 
sible/rom  the  beginning ;  and  it  is  for  such  examples  that  the  treatment 
recommended  by  Sir  Astley  Cooper  for  all  intra-capsular  fractures, 
ouo-ht  to  be  reserved.  , 


(c.)  Fractures  of  the  Neck  partly  within  and  partly  without  the  Capsule. 

It  is  scarcely  necessar}'"  to  say  that  the  line  of  fracture  through  the 
neck  of  the  femur  may  be  such,  that  it  shall  be  in  part  within  and  in 
part  without  the  capsule;  and  such  fractures  will  be  even  more  diffi- 
cult to  diagnosticate  than  either  of  those  forms  of  which  we  have  just 
spoken.     The  symptoms  will  be  mainly,  however,  those  which  cha- 


BASE    OF    THE    TROCHAXTER    :^rAJOR.  389 

Tacterize  fractures  within  the  capsule,  while  the  treatment  ought  to  be 
such  as  we  would  adopt  in  those  fractures  which  are  wholly  without 
the  capsule.  The  chances  for  bony  union  are  increased  in  proportion 
as  the  line  of  separation  extends  outside  of  the  capsule,  and  we  ought 
to  be  diligent  in  our  efforts,  if  we  have  made  ourselves  certain  that  the 
■  fracture  is  partly  extra-capsular, to  secure  a  good  bony  union;  a  result 
which  experience  has  shown  may  be  reasonably  anticipated. 

The  necessity  for  some  extension,  and  of  a  firm  retentive  apparatus 
in  this  form  of  fracture,  furnislies  another  argument  in  favor  of  the 
employment  of  the  same  means  in  fractures  whollj'-  within  the  capsule. 
We  shall  thus  avoid  the  mischief  which  might  arise  from  mistaking  a 
fracture  of  the  character  of  which  we  are  now  speaking,  for  a  fracture 
Avholly  within  the  capsule. 


§  2.  FRACTrKETHKoroH  THE  Trochaxter  AIajor  axd  Base  or  the 
Xeck  of  the  Femur. 

This  fracture,  which  Sir  Astley  Cooper  calls  a  "fracture  of  the  femur 
through  the  trochanter  major,'"  passes  obliquely  upwards  and  outwards 
from  the  lower  portion  of  the  neck,  but  instead  of  traversing  the  neck 
completel}'",  it  penetrates  the  base  of  the  trochanter  major ;  the  line  of 
fracture  being  such  as  to  separate  the  femur  into  two  fragments,  one 
of  which  is  composed  of  the  head,  neck  and  trochanter  major,  and  the 
other  of  the  shaft  with  the  remaining  portions  of  the  femur. 

The  following  two  examples  are  all  in  relation  to  which  we  possess 
any  positive  information,  or  in  which  the  diagnosis  has  been  con- 
firmed by  an  autopsy.    The  first  is  thus  related  by  Sir  Astley  Cooper. 

"The  first  case  of  this  kind  I  ever  saw,  was  in  St,  Thomas's  Hospital, 
about  the  3'ear  1786.  It  was  supposed  to  be  a  fracture  of  the  neck  of 
the  thigh-bone  within  the  capsule,  and  the  limb  was  extended  over 
a  pillow  rolled  under  the  knee,  with' splints  on  each  side  of  the  limb, 
by  Mr.  Cline's  direction.  An  ossific  union  succeeded,  with  scarcely 
any  deformity,  excepting  that  the  foot  was  somewhat  everted,  and  the 
man  walked  extremely  well.  When  he  was  to  be  discharged  from  the 
hospital,  a  fever  attacked  him, of  which  he  died;  and  upon  dissection, 
the  fracture  was  found  through  the  trochanter  major,  and  the  bone 
was  united  with  very  little  deformity,  so  that  his  limb  would  have 
been  equally  useful  as  before.'"^ 

The  second  example  is  reported  by  Mr.  Stanley. 

"A  woman,  in  her  sixtieth  year,  fell  in  the  street  and  injured  her 
right  hip.  On  examination,  the  limb  was  found  slightly  everted,  and 
shortened  to  the  extent  of  three-quarters  of  an  inch,  but  movable  in 
every  direction.  The  extremity  of  the  shaft  of  the  femur  was  in  its 
natural  situation;  but  behind  the  femur,  and  at  a  little  distance  from 
it,  a  bony  prominence  was  discovered,  resting  upon  the  ilium,  toward 
the  great  sciatic  notch,  strongly  resembling  the  head  of  the  femur. 
Various  opinions  were  entertained  as  to  the  nature  of  the  injur\",  some 

1  Sir  Astlev  Cooper,  op.  cit.,  p.  1S3.  ^  Op.  cit.,  p.  184. 


390  FRACTUEES    OF    THE    FEMUR. 

believing  it  to  be  dislocation,  and  others  a  fracture.  After  a  confinement 
of  several  months  to  her  bed,  the  woman  was  sufficiently  recovered  to 
walk  with  the  assistance  of  a  crutch,  and  in  this  state  she  continued 
till  her  death,  which  took  place  about  three  years  after  the  accident, 
during  the  whole  of  which  period  I  had  watched  the  progress  of  the 
case.  Having  obtained  permission  to  examine  the  seat  of  the  injury,  I 
ascertained  that  there  had  been  a  fracture  extending  obliquely  through 
the  trochanter  major,  and  through  the  basis  of  the  neck  into  the  shaft 
of  the  femur,  and  that  the  prominence  which  had  been  mistaken  for 
the  head  of  the  bone  was  occasioned  by  the  posterior  and  larger  por- 
tion of  the  trochanter  drawn  backwards  toward  the  ischiatic  notch."^ 

Sir  Astley  relates  three  other  examples  in  which  he  believes  the 
fractures  to  have  been  of  the  character  above  described ;  and  he  details 
the  peculiar  plans  of  treatment  which,  in  each  case,  he  saw  fit  to  recom- 
mend. I  can  see  no  reason,  however,  why  the  treatment  need  differ 
from  that  which  has  already  been  recommended  for  fractures  of  the 
neck,  since  the  indications  are  nearly  identical  in  all  of  these  cases ; 
namely,  moderate  extension,  and  steady  support  of  the  limb  in  its 
natural  position. 


§  3.  Fracture  of  the  Epiphysis  or  the  Trochanter  Major. 

Sq  far  as  I  know,  the  only  well-authenticated  example  of  this  acci- 
dent is  the  one  reported  by  Mr.  Key  to  Sir  Astley  Cooper.^  The  sub- 
ject of  this  case  was  a  girl,  aged  about  sixteen  years,  who  fell,  March 
15, 1822,  upon  the  side-walk,  and  struck  her  trochanter  violently  against 
the  curb-stone.  She  arose,  and,  without  much  pain  or  difficulty,  walked 
home.  On  the  20th  she  was  received  into  Guy's  Hospital,  and  the  limb 
was  examined  by  Mr.  Key.  The  right  leg,  which  was  the  one  injured, 
was  considerably  everted,  and  appeared  to  be  about  half  an  inch  longer 
than  the  sound  limb.  It  could  be  moved  in  all  directions,  but  abduc- 
tion gave  her  considerable  pain.  She  had  perfect  command  over  all 
the  muscles,  except  the  rotators  inwards.  No  crepitus  could  be  de- 
tected. Four  days  after  admission  she  died,  having  succumbed  to  the 
irritative  fever  which  followed  the  injury. 

The  autopsy  disclosed  a  fracture  through  the  base  of  the  trochanter 
major,  but  without  laceration  of  the  tendinous  expansions  which  cover 
the  outside  of  this  process,  so  that  no  displacement  of  the  epiphysis 
had  occurred,  nor  could  it  be  moved,  except  to  a  small  extent  upwards 
and  downwards.  A  considerable  collection  of  pus  was  found  also  below 
and  in  front  of  the  trochanter. 

The  absence  of  displacement  in  the  fragment,  with  its  peculiar  and 
limited  motion,  sufficiently  explained  why  the  fracture  could  not  be 
detected  during  life. 

In  the  eighth  volume  of  the  Transactions  of  the  Medical  and  Physical 
Society  of  Calcutta  (1835),  J.  Clarke,  Esq.,  reports  a  case  of  comminuted 

'  Stanley,  Med.-Chir.  Trans.,  vol.  xiii. 

^  Sir  Astley  Cooper  on  Dislocations  and  Fractures,  etc.,  Amer.  ed.,  1851,  p.  192. 


EPIPHYSIS    OF    THE    TROCHAISTTEE    MAJOR. 


391 


fracture  of  the  trochanter  major,  which  has  been  mentioned  by  Mal- 
gaigne  as  an  example  of  simple  fracture  of  the  trochanter;  but,  after 
reading  the  case  carefully,  I  cannot  avoid  the  conclusion  that  it  was 
an  example  of  fracture  of  the  neck  without  the  capsule,  accompanied 
with  impaction  and  extensive  comminution.  "Extravasation,"  says 
Mr.  Clarke,  "was  discovered  within  the  capsular  ligament  and  around 
the  trochanter  major ;  and,  on  clearing  away  the  muscles,  the  trochan- 
ter was  found  crushed  and  shattered,  several  pieces  entirely  detached, 
and  fissures  extending  deeply  into  the  shaft  of  the  bone."^ 

I  shall  venture  to  express  the  same  opinion  in  relation  to  the  case 
reported  by  Bransby  Cooper.^  The  diagnosis  was  not  confirmed  by 
an  autopsy,  and  the  testimony  drawn  from  Mr.  Cooper's  account  of 
the  case  is  far  from  being,  to  my  mind,  conclusive.  It  may,  indeed, 
have  been  a  simple  fracture  of  the  epiphysis;  but  there  is  nothing  in 
the  narrative  to  render  it  improbable  tlaat  there  existed  also  an  im- 
pacted extra-capsular  fracture  of  the  neck. 

I  have  also  myself  reported  one  example  of  this  fracture  as  having 
come  under  my  own  observation,^  but  of  which  I  wish  now  to  speak 
somewhat  less  confidently.  The  patient,  James  Eedwick,  a  travelling 
showman,  «t.  23,  fell,  in  August,  1848,  from  a  high  wagon,  striking  upon 
his  left  hip.  When  he  got  upon  his  feet,  he  found  himself  unable  to 
walk,  and  was  carried  to  his  room.  Dr.  Wilcox,  of  this  city,  was  called 
to  see  him,  and  applied  a  long  straight  splint.  Fourteen  days  after 
the  accident  I  saw  the  patient  with  Dr.  Wilcox.  The  thigh  was  not 
appreciably  shortened,  nor  was  there  either  eversion  or  inversion;  but 
the  epiphysis  of  the  trochanter  major  was  carried  upwards  toward  the 
crest  of  the  ilium  half  an  inch,  and  slightly  sent  in.  No  crepitus  could 
be  detected.  The  splint  was  continued  five  weeks;  and  about  a  month 
after,  I  found  the  fragment  in  the  same  place,  but  he  was  able  to  walk 
with  only  a  slight  halt. 

I  think  this  also  may  have  been  an  extra-capsular  impacted  fracture. 

With  the  small  amount  of  positive  information  which  we  possess  in 
relation  to  this  fracture,  we  might  venture  a  few  conjectures  as  to  what 
would  constitute  its  symptoms,  or  as  to  the  probable  results  and  the 


Fig.  126. 


Sir  Astley  Cooper's  mode  of  treating  fractures  of  the  trochanter  major.     (From  A.  Cooper  ) 

'  Clarke,  Amer.  Journ.  Med.  Sci.,  Nov.  1836,  vol.  ix.  p.  181. 
^  B.  Cooper,  A.  Cooper  on  Dislocations,  &c.,  op.  cit.,  p.  192. 
^  Hamilton,  Trans.  Amer.  Med.  Assoc,  op.  cit.,  vol.  x.  p.  254. 


392  ,  FEACTUEES    OF    THE    FEMUE. 

most  suitable  treatment;  but  we  prefer  to  occupy  ourselves  with  a 
simple  statement  of  tlie  facts,  so  far  as  tbey  are  known,  leaving  all 
mere  speculative  inferences  to  those  who  choose  to  make  them. 


§  4.  Fractures  op  the  Shaft  of  the  Femur. 

Etiology. — Unless  the  fracture  has  taken  place  just  above  the  con- 
dyles, or  immediately  below  the  trochanter  minor,  in  a  very  large 
proportion  of  cases  it  has  been  produced  by  a  direct  blow,  such  as 
the  passage  of  a  loaded  vehicle  across  the  thigh,  or  the  fall  of  a  piece 
of  timber  directly  upon  it.  An  analysis  of  twenty-one  cases,  taken 
indiscriminately,  presents  three  fractures  immediately  above  the  con- 
dyles, and  these  were  all  produced  by  falls  upon  the  feet;  but  of  the 
remaining  eighteen,  all  of  which  occurred  higher  in  the  limb,  only 
two  were  the  result  of  falls  upon  the  feet  or  of  indirect  blows,  and 
one  of  these  was  a  fracture  just  below  the  trochanter  minor. 

Paihohgy. — It  has  already  been  remarked  that  this  bone  is  most 
frequently  broken  in  its  middle  third :  thus,  of  eighty-nine  fractures 
of  the  shaft,  eighteen  occurred  in  the  upper  third,  twenty-one  in  the 
lower  third,  and  fifty  in  the  middle  third.  I  have  made  the  same 
observation  in  an  examination  of  specimens  belonging  to  Dr.  Mutter. 
In  his  cabinet,  of  twenty  four  fractures  of  the  shaft,  three  belonged  to 
the  upper  third,  two  to  the  lower,  and  nineteen  to  the  middle  third. 

Inthe  adult,  these  fractures  are,  with  only  an  exceedingly  rare  ex- 
ception, oblique;  and  the  obliquity  is  generally  greater  than  in  the 
case  of  oiher  bones.  This  fact,  which  it  is  very  difficult  to  deter- 
mine, in  most  cases,  upon  the  living  subject,  I  have  established 
by  a  considerable  number  of  observations  made  upon  cabinet  speci- 
mens. A  transverse  fracture  is  found  only  twice  in  Dr.  Mussey's 
collection,  containing  thirty  examples  of  fracture  of  the  shaft;  and  in 
Dr.  Mutter's  collection,  specimen  B  71  is  an  adult  femur,  broken 
nearly  transversely  through  its  middle  third;  and  it  is  united  with  a 
shortening  of  about  one  inch.  Indeed,  it  is  more  common  to  find  a 
transverse  fracture  in  the  middle  third  than  at  any  other  point  of  the 
bone;  but  in  the  upper  third  the  obliquity  is  extreme  and  almost 
constant. 

At  whatever  point  of  the  shaft  the  bone  is  broken,  the  degree  of 
obliquity  is  generally  such  that  the  fragments  cannot  support  each 
other  when  placed  in  apposition  ;  unless  indeed  the  fracture  is  near 
the  condyles,  where  the  greater  breadth  of  the  bone  creates  an  addi- 
tional support;  but  even  here,  the  cabinet  specimens  still  present  a 
striking  obliquity  with  more  or  less  overlapping.  I  believe  that  in 
each  of  the  three  specimens  of  fracture  at  this  point  found  in  the 
collection  belonging  to  the  Albany  Medical  College,  the  obliquity  is 
such  that  the  fragments  were  not  supported,  and  an  overlapping  has 
taken  place.  In  specimen  719  the  fracture  extends  into  the  joint ;  and 
although  it  is  united  by  bone,  a  shortening  of  about  one  inch  has 
occurred. 

In  the  case  of  children,  and  especially  of  infants,  the  rule  is  reversed ; 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


393 


Fig.  127. 


the  bone  is  either  broken  transversely  or  nearly  transversely,  or  it 
is  serrated  or  denticulated,  so  that  complete  lateral  displacement  is 
much  less  frequent. 

The  same  remark  is  probably  true  of  some  fractures  occurring  in 
extreme  old  age;  but  as  the  shaft  of  the  femur  is  not  often  broken  in 
very  old  persons,  owing  to  the  readiness  with  which  the  neck  yields 
to  violence,  I  have  not  had  any  opportunity  to  verify  this  opinion. 

The  direction  of  the  obliquity  varies  exceedingly,  especially  in  the 
middle  and  upper  thirds;  in  the  middle  third,  however,  it  is  generally 
downwards  and  inwards ;  but  in  the  lower  third,  its  direction  is,  with 
only  rare  exceptions,  downwards  and  forwards,  and  the  superior  frag- 
ment is  found  lying  in  front  of  the  inferior. 

In  one  instance  I  have  found  both  femurs  broken  at  the  same  point, 
and  in  the  same  manner.  Mr.  L.  Brittin,  aged 
about  fifty-five  years,  while  employed  upon  a 
building,  fell  from  a  four  h  story  window  upon 
the  stone  pavement  below,  striking  upon  his 
feet.  In  addition  to  several  other  fractures, 
I  found  both  femurs  broken  obliquely  down- 
wards and  forwards,  just  above  the  condyles. 
Very  little  inflammation  ensued,  and  although 
it  was  found  impossible  to  employ  extension, 
union  occurred  readily,  and  with  only  a  mode- 
rate overlapping.  In  the  left  limb,  however, 
the  upper  fragment  pressed  down  sufficiently 
to  interfere  somewhat  with  the  patella,  and 
the  patient  is  unable  now,  after  the  lapse  of 
several  months,  to  straighten  the  knee  com- 
pletely. The  motions  of  the  right  knee  are 
unimpaired. 

.  I  have  only  once  met  with  a  fracture  at 
this  point,  in  which  the  line  of  separation  was 
downwards  and  backwards.   As  the  case  pre- 
sents several  points  of  interest,  it  will  be  proper  to  narrate  the  facts 
somewhat  at  length. 

George  Taylor  Aikin,  of  Lockport,  N.  Y.,  set,  7.  May  18,  1854,  in 
jumping  down  a  bank  of  about  three  feet  in  height,  he  broke  the  right 
thigh  obliquely,  just  above  the  knee-joint.  Direction  of  the  fracture 
obliquely  downwards  and  backwards. 

Dr.  G.,  an  accomplished  surgeon,  residing  in  Lockport,  was  called. 
The  limb  was  not  then  much  swollen.  He  applied  side  splints,  rollers, 
&c.,  carefully,  and  then  laid  the  limb  over  a  double  inclined  plane. 
The  knee  was  elevated  about  six  or  eight  inches.  Before  applying 
the  splints,  suitable  extension  had  been  made,  and  after  completing 
the  dressings,  the  two  limbs  seemed  to  be  of  the  same  length. 

On  the  second  or  third  day.  Dr.  G.  noticed  that  the  toes  looked  un- 
naturally white,  and  were  cold. 

Counsel  was  now  called  at  the  request  of  Dr.  G.,  when  it  was  de- 
termined to  abandon  all  dressings  and  direct  their  efforts  solely  to 
savino;  the  limb. 


Fracture  at  base  of  condyles. 


394  TEACTUEES    OF    THE    FEMUE. 

The  result  was  that  slowly  a  considerable  portion  of  his  foot  died 
and  sloughed  away,  leaving  only  the  tarsal  bones.  The  fracture  united, 
but  with  considerable  overlapping  and  deformity. 

Feb.  26,  1856,  the  boy  was  brought  to  me  by  his  father.  On  ex- 
amining the  fracture  I  noticed  that  the  anterior  line  of  the  femur 
seemed  nearly  straight,  and  this  appearance  was  owing  in  some 
degree  to  the  muscles,  which  covered  and  concealed  the  bone,  and 
in  some  degree,  also,  to  the  manner  in  which  the  fragments  rested 
upon  each  other:  the  pointed  superior  end  of  the  lower  fragment  rest- 
ing snugly  upon  the  front  of  the  upper  fragment,  so  that  no  abrupt 
angle  existed  in  front.  On  the  back  of  the  limb,  however,  the  lower 
end  of  the  upper  fragment,  quite  sharp,  projected  freely  downwards 
and  backwards  into  the  popliteal  space,  so  that  its  extreme  point  was 
only  about  half  an  inch  above  the  line  of  the  articulation.  The  limb 
had  shortened  one  inch,  and  this  enabled  us  to  determine  accurately 
that  the  lower  point  or  the  commencement  of  the  fracture  was  one 
inch  and  a  half  above  the  articulation,  while  the  point  where  the  line 
of  fracture  terminated  in  front,  was  probably  quite  three  inches  and 
a  half  above  the  joint. 

The  motions  of  the  knee-joint  were  pretty  free.  The. leg  was  ex- 
tremely wasted,  and  the  anterior  half  of  the  foot  having  sloughed  off, 
the  sores  had  now  completely  healed  over.  He  was  able  to  walk  toler- 
ably well  without  either  crutch  or  cane. 

Subsequently,  Dr.  G.  found  it  necessary  to  sue  the  father  of  the  child 
for  the  amount  of  his  services,  when  Mr.  Aikin  put  in  a  plea  of  mal- 
practice, and  that  consequently  the  services  were  without  value. 

The  case  was  tried  in  the  March  term  of  the  Niagara  circuit  of  1856, 
at  Lockport,  N.  Y.,  the  Hon.  Benj.  F.  Greene  presiding. 

On  the  part  of  the  defence  it  was  claimed  that  the  death  of  the  foot 
was  in  consequence  of  the  bandages  being  too  tight.  They  failed, 
however,  to  show  that  they  were  extraordinarily  or  unduly  tight. 
While  on  the  part  of  Dr.  G.,  the  prosecutor,  it  was  shown  that  the  death 
of  the  toes  was  preceded  by  a  total  loss  of  color,  and  that  it  was  not 
accompanied  with  either  venous  or  arterial  congestion.  The  medical 
gentlemen  examined  as  witnesses,  declared  that  this  circumstance  fur- 
nished the  most  positive  evidence  which  could  be  desired,  that  the 
death  of  the  toes  was  not  due  to  the  tightness  of  the  bandages,  but  that 
its  cause  must  be  looked  for  in  an  arrest  of  the  arterial  or  nervous 
currents  supplying  the  limb,  or  in  both.  They  believed,  also,  that 
the  projection  of  the  superior  fragment  into  the  popliteal  space  was 
sufficient  to  cause  this  arrest.  They  also  believed  that  overlapping 
and  consequent  projection  could  not  have  been  prevented  in  this 
case,  and  that,  therefore,  the  treatment  was  not  responsible  for  this 
unfortunate  result:  indeed,  they  regarded  the  treatment  as  correct, 
and  the  result  as  a  triumph  of  skill,  in  that  any  portion  of  the  limb 
was  saved;  the  leg  and  foot  now  remaining  being  far  more  useful  than 
any  artificial  leg  and  foot  could  be. 

The  Hon.  Judge,  in  a  speech  remarkable  for  its  clearness  and  liber- 
ality, sought  to  impress  upon  the  jury  the  value  of  the  medical  testi- 
mony. The  jury  returned  a  verdict  for  Dr.  G.,  allowing  the  amount 
of  his  claim  for  services,  with  the  costs  of  suit. 


FRACTURES    OF    THE    SHAFT    OF    THE    FEMUR.  395 

Specimen  121,  in  Dr.  March's  collection  at  Albany,  presents  a 
similar  disposition  of  the  fragments.  The  fracture  is  oblique,  from 
above  downwards  and  backwards,  and  the  upper  portion  lies  behind 
the  lower.  It  is  firmly  united  by  bone,  but  with  an  overlapping  of 
from  two  and  a  half  to  three  inches.  The  young  gentleman  who 
showed  me  the  specimen  remarked  that  it  had  been  found  impossible, 
owing  to  an  ulcer  upon  the  heel,  and  to  other  causes,  to  employ  in  the 
treatment  any  degree  of  extension. 

These  two  are  the  only  examples  which  have  come  under  my  obser- 
vation in  which  a  fracture  at  this  point  has  taken  this  direction.  ■ 

Sir  Astley  Cooper  does  not  seem  to  have  recognized  this  form  of 
fracture  and  displacement.  Amesbury  has,  however,  recorded  one 
case,  which  came  under  his  own  observation,  where,  although  the 
bloodvessels  and  nerves  escaped,  the  bone  projected  through  the  skin 
in  the  ham,  and  finally  exfoliated.^  And  he  thinks  the  point  of  bone 
may  sometimes  so  penetrate  the  artery  and  injure  the  nerves  as  to 
render  amputation  necessary,  in  order  to  save  the  life  of  the  patient. 

M.  Coural  also  has  related  a  case  in  which  an  epiphysary  disjunc- 
tion, occurring  in  a  child  twelve  years  old,  was  attended  with  a  dis- 
placement of  the  upper  fragment  backwards,  and  amputation  became 
necessary,^ 

I  know  of  no  other  cases  of  this  rare  accident  which  have  been  re- 
ported. Lonsdale  refers  to  it  as  "the  rarest  direction  for  a  fracture  to 
take;"  and  thinks  that  in  case  of  its  occurrence,  the  vessels  in  the  popli- 
teal space  will  stand  a  chance  of  being  wounded;  but  he  mentions  no 
example.  The  popliteal  artery  hugs  the  bone  so  closely  at  this  point, 
that  a  displacement  of  the  upper  fragment  in  a  direction  downwards 
and  backwards  must  always  greatly  endanger  its  integrity.  Indeed, 
it  is  here  that  the  artery  and  vein  are  in  the  closest  contact  with  each 
other,  and  with  the  bone ;  an  anatomical  fact,  which  has  been  used  by 
E-icherand  and  others  to  explain  the  greater  frequency  of  aneurisms 
in  the  ham. 

The  direction  of  the  displacement,  however,  in  fractures  of  the  shaft 
of  the  femur,  does  not  always  depend  upon  the  direction  of  the  line  of 
fracture.  In  fractures  of  the  upper  third,  whatever  may  be  the  direc- 
tion of  the  line  of  fracture,  the  lower  end  of  the  upper  fragment  inclines 
forwards  and  outwards,  and  the  upper  end  of  the  lower  fragment  in- 
wards; unless,  indeed,  this  inclination  is  controlled  by  actual  entangle- 
ment of  the  broken  ends  with  each  other. 

In  the  middle  third  the  fragments  also  generally  take  the  same 
relative  position,  whatever  may  be  the  direction  of  the  fracture;  but 
when  the  fracture  takes  place  at  or  near  the  condyles,  where  the 
diameter  of  the  bone  is  much  greater,  the  direction  of  the  obliquity 
determines  pretty  uniformly  the  direction  of  the  displacement. 

Symptoms. — The  symptoms  which  characterize  a  fracture  of  the 
shaft  of  the  femur  are  those  which  are  common  to  all  fractures, 
namely,  mobility,  crepitus,  displacement  of  the  fragments,  pain,  and 

'  Remarks  on  Fractures,  &c.,  by  Joseph.  Amesbury,  vol.  i.  p.  293.    London,  1831. 
'^  Archiv    Gen.  de  Med.,  torn.  ix.  p.  267. 


396  FEACTUEES    OF    THE    FEMUR. 

swelling,  to  which  are  added  generally  a  shortening  of  the  limbj  with 
eversion  of  the  foot  and  leg. 

Owing  to  the  great  amount  of  muscle  covering  the  thigh,  and  some- 
times to  the  swelling  which  immediately  follows  the  injury,  it  is  often 
very  difficult  to  determine  at  what  precise  point  the  fracture  has  occur- 
red, and  still  more  diflBcult  to  say  whether  the  fracture  is  oblique  or 
transverse;  indeed,  this  latter  question  is  sometimes  decided  approxi- 
matively  by  a  reference  to  the  age  of  the  patient  rather  than  by  the 
examination  of  the  limb. 

The  immediate  shortening  varies  from  half  an  inch  to  an  inch  and 
a  half,  or  even  more,  and  it  will  average  about  one  inch  in  the  case  of 
healthy  adults. 

Prognosis. — Whatever  may  have  been  the  general  opinion  of  ex- 
perienced surgeons  as  to  the  question  of  shortening  in  other  fractures, 
very  few  certainly  have  ever  claimed  that  in  fractures  of  the  femur  a 
complete  restoration  of  the  bone  to  its  original  length  was  generally 
to  be  expected.  There  seems,  however,  to  have  existed  only  certain 
vague  and  indefinite  notions  as  to  the  proportion  and  amount  of  this 
shortening,  and  which  have  had  for  their  basis  nothing  better  than  a 
few  imperfectly  analyzed  observations. 

SaysScultetus  (quoting  first  from  Hippocrates):  "  'For  the  bones  of 
the  thigh,  though  you  do  draw  them  out  by  force  of  extension,  cannot 
be  held  so  by  any  hands;  but  when  the  first  intension  slacks,  they  will 
run  together  again  ;  for  here  the  thick  and  strong  flesh  are  above  bind- 
ing, and  binding  cannot  keep  them  down.' — Hippocrates  defract.  Which 
Celsus  seems  to  confirm,  Lib,  8,  cap.  10,  where  he  writes  as  follows  of 
the  cure  of  legs  and  thighs :  '  E'or  we  must  not  be  ignorant  that  if  the 
thigh  be  broken,  that  it  will  be  made  shorter,  because  it  never  returns 
to  its  former  state.'  And  Avicenna,  Lib.  4,  Fen.  5,  saith  '  that  it  is  a 
rare  thing  for  the  thigh  once  broken,  to  be  perfectly  cured  again.' 

"These  words  admonish  us,"  continues  Scultetus,  "that  we  should 
never  promise  a  perfect  cure  of  the  thigh ;  but  rather,  using  all  dili- 
gence, we  should  foretell  that  it  is  doubtful  that  the  patient  will  be 
always  lame;  but  when  this  shall  happen  from  the  nature  of  the  frac- 
ture, or  which  most  frequently  falls  out,  from  the  impatience  of  the 
sick  person,  it  may  be  imputed  to  our  mistake;  and  instead  of  a  re- 
ward, bring  us  a  disgrace."^ 

Says  Chelius:  "Fracture  of  the  thigh-bone  is  always  a  severe  acci- 
dent, as  the  broken  ends  are  retained  in  proper  contact  with  great 
difficulty.  The  cure  takes  place  most  commonly  with  deformity  and 
shortening  of  the  limb,  especially  in  oblique  fractures,  and  those  which 
occur  in  the  upper  and  lower  third  of  the  thigh-bone.  Compound 
fractures  are  so  much  more  difficult  to  treat."-^ 

Maclise,  while  commenting  somewhat  indefinitely  upon  certain  plans 
of  treatment,  takes  occasion  to  say:  "Out  of  every  six  fractures  of 
either  clavicle  or  thigh-bone,  I  believe  that  as  the  result  of  our  treatment 
by  the  present  forms  of  mechanical  contrivances,  there  would  not  be 

•  The  Cliirurgeon's  Store-house,  by  Johannes  Scultetus,  a  Famous  Physician,  and 
Chirurgeon  of  Ulnae  in  Suevia.     London,  1674. 

'  System  of  Surgery,  by  J.  M.  Chelius.  translated,  &c.,  by  South.  First  Amer.  ed., 
vol.  i.  p.  627,  1847.     See  also  p.  625,  paragraph  679. 


FEACTUEES    OF    THE    SHAFT    OF    THE    FEMUE.  397 

found  three  cases  of  coaptation  of  the  broken  ends  of  the  bone  so  com- 
plete as  to  do  credit  to  the  surgeon.'" 

Says  John  Bell :  "  The  machine  is  not  yet  invented  by  which  a 
fractured  thigh-bone  can  be  perfectly  secured."  And  Benjamin  Bell 
declares  that  "  an  effectual  method  of  securing  oblique  fractures  in  the 
bones  of  the  extremities,  and  especially  of  the  thigh-bone,  is  perhnps 
one  of  the  greatest  desiderata  in  modern  surgery,"  "In  all  ages,"  he 
adds,  "the  difficulty  of  this  has  been  confessedly  great;  and  frequent 
lameness  produced  by  shortened  limbs  arising  from  this  cause,  evidently 
shows  that  we  are  still  deficient  in  this  branch  of  practice."^ 

Colles  observes,  that  "  although  three  or  four  methods  of  treatment 
are  practised,  the  pieces  at  the  conclusion  are  often  found  overlapped."^ 
One  reason  for  which,  in  his  opinion,  is  a  too  blind  adherence  to  the 
principles  recommended  by  Pott, 

Yelpeau  says,  that  "after  fractures  of  the  femur,  there  is  no  limp- 
ing unless  the  shortening  exceeds  three-quarters  of  an  inch;  and  the 
same  is  true  if  the  shortening  occurs  in  the  tibia,"  The  reason  is,  that 
the  pelvis  inclines  toward  the  shorter  limb,  and  thus  compensates  for 
the  deficiency  in  length.  In  speaking  of  the  various  contrivances  for 
dressing  the  fractured  femur,  he  remarks  that  "most  of  them  fail  to  ob- 
viate the  shortening,  and  produce  eschars,  anchylosis,  or  troublesome 
arrests  of  the  circulation.  This  is  the  price  that  is  usually  paid  for 
the  employment  of  these  complicated  machines,  and  a  shortening  of  a 
quarter  to  three-quarters  of  an  inch  is  not  avoided  after  all.  The 
simplest  apparatus  that  will  maintain  the  adjustment  of  the  fractured 
femur,  so  that  union  may  take  place  with  shortening  of  only  half  an 
inch,  is  the  best."'' 

Nelaton  holds  the  following  language.* — 

"A  fracture  of  the  body  of  the  femur,  with  an  adult,  is  always  a 
grave  accident,  inasmuch  as  it  demands  so  long  a  confinement  to  the 
bed,  and  especially  on  account  of  the  shortening  of  the  limb,  which  it 
is  almost  impossible  whollj''  to  prevent;  accordingly,  Boyer  recommends 
to  the  surgeon,  from  the  first  day,  to  announce  to  the  parents  of  the 
patient  the  possibility  of  this  accident.  With  infants,  on  the  contrary, 
it  is  almost  always  easy  to  avoid  the  shortening."^ 

While  Malgaigne  declares  his  opinion  on  this  subject  thus,  at 
length: — 

"  When  we  do  not  succeed  in  drawing  back  the  displaced  fragments, 
end  to  end,  so  that  they  may  oppose  themselves  to  the  action  of  the 
muscles,  it  is  impossible  to  preserve  to  the  member  its  normal  length, 
whatever  may  be  the  appareil  or  method  employed.  Surgeons  are  not 
sufficiently  agreed  upon  this  question. 

'  Surgical  Anatomy,  by  Joseph.  Maclise,  Surgeon.  First  Amer.  ed.  Part  I.  p.  36, 
1851. 

^  System  of  Surgery,  by  Benjaminr  Bell,  vol.  vii.  p.  21.     Edinburgh,  1801. 

*  Lectures  on  the  Theory  and  Practice  of  Surgery,  by  Abraham  Colles  (Dublin), 
p.  321.     Philadelphia  ed.,  1845. 

*  Peninsular  Journ.  of  Med.,  vol.  iii.  p.  384 ;  also  Memphis  Med.  Journ.,  vol.  iv.  p. 
254,  1856. 

^  Elemens  de  Pathologic  Chirurgicale,  par  A,  Nelaton,  tom.  prem.,  p,  752,  Paris, 
1844, 


398  FEACTUEES    OF    THE    FEMUE. 

"  Hippocrates  gives  us  to  understand,  that  we  can  always  correct 
the  shortening;  Celsus,  falling  into  the  opposite  error,  declared,  that 
a  broken  thigh  always  remains  shorter  than  the  other.  At  a  period 
quite  recent,  Desault  pretended  to  cure  all  fractures  without  shortening, 
and  his  journal  contains  several  examples.  In  imitation  of  Desault, 
various  practitioners  have  modified,  corrected,  and  improved  the  ap- 
paratus for  permanent  extension,  and  they  claim  to  have  themselves 
obtained  as  complete  success.  I  ought  then  to  declare  here  in  the 
most  positive  manner,  that  I  have  never  obtained  like  results,  either 
in  the  use  of  my  own  apparatus,  or  with  that  of  others,  nor  indeed 
where  in  pursuance  of  my  invitation,  several  inventors  have  applied 
their  apparatus  in  my  wards.  I  have  examined,  more  than  once,  per- 
sons declared  cured  without  shortening,  and  yet,  upon  measurement, 
the  shortening  was  always  manifest.  The  misfortune  of  all  those  who 
believe  that  they  have  obtained  those  miraculous  cures,  is  that  they 
have  not  even  thought  of  instituting  a  comparative  measurement  of 
the  two  limbs;  I  will  say  even  more,  that  they  are  most  generally 
ignorant  of  the  conditions  of  a  good  and  faithful  measurement. 
Sometimes,  also,  they  have  been  deceived  in  another  way;  in  falling 
upon  fractures  which  were  not  displaced,  especially  with  young  per- 
sons, and  they  have  believed  that  they  have  cured  with  their  appara- 
tus a  shortening  which  had  never  existed.  In  short,  when  the  frag- 
ments are  not  displaced,  or  even  when  they  are  brought  again  into 
a  contact  maintained  by  their  reciprocal  denticulations,  it  is  easy  to 
cure  the  fracture  of  the  femur  without  shortening;  aside  of  those  two 
conditions,  the  thing  is  simply  impossible. 

"Several  distinguished  surgeons  of  our  day  have  acknowledged  this 
impossibility,  and  have  renounced,  in  consequence,  permanent  exten- 
sion. They  allege,  moreover,  that  an  overriding  of  even  three  centi- 
metres is  of  little  importance,  and  occasions  no  limping.  I  cannot 
agree  with  this  opinion.  I  have  seen  persons  walk  verj^  well  with  a 
shortening  of  one  centimetre;  beyond  this  limit,  either  they  limp,  or 
they  have  lifted  the  heel  of  the  shoe,  or,  in  short,  the  limping  is  only 
concealed  by  a  lateral  deviation  of  the  spine.^  We  thus  are  made  to 
comprehend  how  a  fracture  with  overlapping  is  always  serious,  and 
how  cautious  we  ought  to  be  in  our  prognosis."^ 

That  the  foregoing  remarks  are  intended  by  the  author  to  be  equally 
applicable  to  other  fractures  of  the  shaft  of  the  femur  than  to  those  of 
the  middle  third,  is  made  evident  by  what  he  has  said  before,  when 
speaking  of  fractures  of  the  upper  third. 

"The  prognosis  is  sufficiently  favorable  when  the  fragments  are  den- 
ticulated (engrenees):  when  they  ride,  on  the  contrary,  we  must  look 
for  a  shortening  as  almost  inevitable." — Ibid.,  p.  718. 

In  our  own  country  several  of  the  most  distinguished  surgeons  have 
testified  to  the  constant  difficulty,  if  not  impossibility,  of  curing  frac- 

'  Dr.  Buck,  of  New  York,  thinks  that  with  a  shortening  of  one  inch,  or  even  one 
inch  and  a  half,  the  patient  may  have  "  a  useful  limb,  with  little  or  no  halting  in  his 
gait."     N.  Y.  Journ.  of  Med.,  vol.  xvi.  p.  294. 

^  Traits  des  Fractures  et  des  Luxations,  par  J.  M.  Malgaigne,  torn.  prem.  pp.  723, 
724.     Paris,  1847. 


FRACTURES    OF    THE    SHAFT    OF    THE    FEMUR.  399 

tures  of  this  bone  without  a  shortening.  In  a  suit  instituted  against 
a  surgeon  in  New  York  city,  for  alleged  malpractice  in  the  treatment 
of  an  oblique,  comminuted,  and  otherwise  compli-^ated  fracture  of  the 
femur  near  its  condyles,  Dr.  Mott  is  reported  to  have  testified  that 
"more  or  less  shortening  of  the  limb  is  uniformly  the  result  after 
fractured  thigh,  even  in  the  most  favorable  circumstances."^ 

In  a  very  interesting  communication  made  to  the  author  by  Jona- 
than Knight,  of  Xew  Haven,  late  President  of  the  American  Medical 
Association,  occurs  the  following  passage : — 

"  I  have  seen  but  few  fractures  of  the  femur  in  the  adult,  unless  of 
the  most  simple  kind,  in  which  there  was  not  some  remaining  de- 
formity ;  often  slight,  so  as  not  to  impair  the  usefulness  of  the  limb, 
and  in  others  considerable  and  apparent^  unavoidable."  Dr.  Knight 
adds,  however:  "In  the  greater  proportion  of  the  fractui'es  in  children, 
the  recovery  has  been  so  nearly  perfect  that  no  marked  deformity  or 
lameness  has  followed." 

Says  Dr.  Gibson :  "Had  the  surgeon  no  other  diflBculties  to  encoun- 
ter than  such  as  present  themselves  after  simple  transverse  fracture  of 
the  shaft  of  the  thigh-bone,  he  would  have  little  reason  to  complain  of 
the  defectiveness  of  art,  or  of  the  power  of  nature  in  promoting  a  cure. 
So  different,  however,  from  this  is  the  result  of  an  oblique  fracture  of 
the  body  of  the  bone,  or  of  a  transverse  fracture  of  its  neck,  that  it  is 
hardly  possible  in  any  case  to  calculate  with  certainty  upon  reunion 
without  more  or  less  shortening  and  deformity  of  the  limb."^ 

Dr.  Detmold,  in  his  remarks  made  before  the  New  York  Academy 
of  ]\redicine,  at  its  meeting  in  March,  1855,  declared  his  belief  that  a 
shortening  of  the  femur  always  occurs  after  fracture,  and  that  "but 
one  inch  of  shortening  in  an  average  of  twenty  cases  is  a  good  result."'^ 

Dr.  J.  Mason  Warren,  of  Boston,  writes  to  me  as  follows :  "As  you 
are  making  observations  on  fractures,  I  would  state  that,  after  a  long 
and  very  careful  observation,  I  have  never  yet  seen,  either  in  Boston 
or  elsewhere,  an  oblique  fracture  of  the  thigh,  in  a  patient  over  seven- 
teen years  of  age,  in  which  there  was  not  some  shortening.  I  have 
had  cases  shown  to  me  in  which  it  was  averred  that  the  limb  was  not 
shortened,  but  on  measuring  myself  I  have  found  the  fact  otherwise. 
In  children,  I  believe  that  union  without  shortening  may  be  accom- 
plished." 

In  a  paper  published  by  Dr.  Lente  in  the  number  of  the  Keio  York 
Journal  of  Medicine  for  September,  1851,  he  states  that  he  believes  the 
average  shortening  after  treatment  in  the  New  York  Hospital  to  be 
three-quarters  of  an  inch  ;  but  subsequently  Dr.  Buck,  one  of  the 
hospital  surgeons,  has  furnished  Dr.  Lente  with  more  exact  statistics. 
Says  Dr.  Buck  : — 

"After  carefully  scrutinizing  over  one  hundred  cases  of  fracture  of 
the  femur,  taken  from  the  register  of  the  N.  Y.  Hospital,  and  elimi- 

'  Boston  Med.  and  Surg.  .Journ.,  vol.  sxsiv.  p.  450.  See  also  opinions  of  Drs.  Reese, 
Post,  Parker,  Clieeseman,  Wood,  &c.,  in  relation  to  the  prognosis  in  this  particular  case. 

^  Institutes  and  Practice  of  Surgery,  by  Wm.  Gibson,  8tb  ed.,  vol.  i.  p.  297.  Phila- 
delphia, 1841. 

^  New  York  Journ.  of  Med.,  second  series,  vol.  xvi.  p.  261. 


400  FEACTUEES    OF    THE    FEMUR. 

nating  such  as  involved  the  cervix,  or  condyles,  or  belonged  to  the 
class  of  compound  fractures,  there  remained  an  aggregate  of  seventy- 
four  cases,  of  both  sexes,  and  of  all  ages  from  3  to  63,  in  which  the 
shaft  of  the  femur  alone  was  fractured.  In  all  these  cases,  the  differ- 
ence in  the  length  of  the  fractured  limb  resulting  from  the  treatment 
was  ascertained  by  careful  measurement  with  a  graduated  tape,  and 
the  following  deductions  were  drawn  from  the  analysis: — 

Of  the  74  cases  of  all  ages,  19  resulted  without  any  shortening,  a 
proportion  of  about  one-fourth.  The  average  shortening  of  the  re- 
maining 55  cases  was  a  fraction  less  than  f  of  an  inch. 

Seventeen  cases  in  the  above  aggregate  were  under  12  years  of  age, 
of  which  six  resulted  without  any  shortening,  a  proportion  of  about 
one-third.  The  average  shortening  in  the  remaining  11  cases,  was  a 
fraction  less  than  one-half  an  inch. 

Of  the  57  cases  over  12  years  of  age,  13  resulted  without  any  short- 
ening, a  proportion  of  about  one-fourth;  and  the  average  shortening  in 
the  remaining  44  cases  was  a  fraction  over  |  of  an  inch.^ 

It  is  not  to  be  denied,  however,  that  a  few  surgeons  in  all  parts  of 
the  world  have  claimed,  and  still  continue  to  claim,  in  their  own  prac- 
tice, or  from  the  adoption  of  their  own  peculiar  plans  of  treatment, 
much  better  success.  Indeed,  some  of  them  do  not  hesitate  to  affirm 
that,  as  a  general  rule,  any  degree  of  shortening  is  quite  unnecessary. 

Mr.  Amesbury  declares,  that  when  the  fracture  is  in  the  "  middle 
or  lower  third,"  under  a  "judiciously  managed"  application  of  his  own 
splint,  "consolidation  of  the  bone  takes  place  without  the  occurrence 
of  shortening  of  the  limb,  or  any  other  deformity  deserving  of  par- 
ticular notice."^ 

Mr.  South,  in  a  note  commenting  upon  an  opposite  sentiment  ex- 
pressed by  Chelius,  and  already  quoted,  remarks :  "  In  simple  fractures 
of  the  thigh-bone,  except  with  great  obliquity,  I  have  rarely  found 
difficulty  in  retaining  broken  ends  in  place,  and  in  effecting  the  union 
without  deformity,  and  with  very  little,  and  sometimes  without  any 
shortening.  For  the  contrary  results  the  medical  attendant  is  mostly 
to  be  blamed,  as  they  are  usually  consequent  upon  his  carelessness  or 
ignorance.''^ 

Mr.  Hunt,  of  the  Queen's  Hospital,  at  Birmingham,  who  treats  all 
fractures  with  the  apparatus  imm.ohiJe  of  Suetin,  has  published  the 
results  of  his  observations;  and  of  the  simple  fractures  of  the  femur 
only  one  presented,  after  the  cure,  any  degree  of  shortening;  and  he 
adds,  that  all  other  fractures  which  he  has  treated  b}'-  this  method  were 
followed  by  "equally  good  results."^  In  relation  to  which  statements, 
Mr.  Gamgee  exclaims :  "  This  is  conservative  surgery.  What  other 
mode  of  treatment  would  have  given  such  results?  And  those  cases 
are  not  exceptional.     Mr.  Hunt  tells  us  he  has  selected  them  from 

'  Buffalo  Med.  .Journ.,  vol.  xv.  p.  22,  .Tune,  1859. 

2  Practical  Remarks  on  Fractures,  by  Joseph  Amesbury,  vol.  i.  p.  384,  London  ed., 
]831. 

3  Op.  cit.,  vol.  i.  p.  627. 

*  Researches  on  Pathological  Anatomy  and  Clinical  Surgery,  by  Joseph  Sampson 
Gamgee.     London  ed.,  pp.  159,  160. 


FRACTUEES    OF    THE    SHAFT    OF    THE    FEMUR.  401 

amongst  many  others  equally  successful.  They  accord  with  the  ex- 
perience recorded  in  my  little  treatise  on  this  subject;  and  the  works 
of  Suetin,  Burggrasve,  Crocq,  Yelpeau,  and  Salvagnoli  Marchetti, 
record  numerous  cases  no  less  remarkable  and  demonstratively  con- 
clusive."^ 

Desault,  also,  according  to  the  passage  from  ]\[algaigne,  which  I 
have  already  quoted,  "  pretended  to  cure  all  fractures  without  short- 
ening." I  do  not  find,  however,  any  other  authority  for  this  statement, 
as  here  made;  neither  in  his  Treatise  oii  Fractures  and  Luxations^ 
edited  by  Bichat,  nor  elsewhere.  Bichat  even  says  positively,  that 
"  Desault  himself  did  not  always  prevent  the  shortening  of  the  limb."^ 
He  declares,  however,  that  "  Desault  has  cured,  at  the  Hotel  Dieu,  a 
vast  number  of  fractures  of  the  os  femoris,  without  the  least  remaining 
deformity."-' 

Dr.  Dorsey,  of  Philadelphia,  who  employed  the  apparatus  of  Desault, 
as  modified  by  Physick  and  Hutchinson  (Fig.  128),  was  equally  suc- 
cessful.'* 

Fi?.  128. 


Phtsick's  Spli>-t. — The  splint  is  intended  to  reach,  to  the  axilla,  but  the  connter-extension  is  made  by 
a  perineal  band.     Physick  employed  also  a  second,  long,  inside  splint. 

Dr.  Scott,  of  Montreal,  Prof,  of  Clinical  Surgery  in  the  McGill 
College,  and  Physician  to  the  "Montreal  General  Hospital,  has  reported 
19  cases  of  fractures  of  the  long  bones,  taken  promiscuously  and 
without  selection,  from  his  hospital  service,  of  which  3  belonged  to 
the  clavicle,  7  to  the  femur,  8  to  the  tibia  and  fibula,  and  1  to  the 
condyles  of  the  humerus.  All  of  which  recovered  without  any  degree 
of  shortening  or  deformity ;  except  the  case  of  fracture  of  the  condyles 
of  the  humerus,  which  resulted  in  death.^ 

It  is  never  a  pleasant  duty  to  call  in  question  the  accuracy  of  an- 
other's statements,  as  to  what  he  has  himself  alone  seen  and  expe- 
rienced. The  circumstances  which  would  justify  such  an  expression 
of  scepticism,  where  the  witnesses,  as  in  this  case,  are  presumed  to  be 
intelligent  and  honest  men,  must  be  extraordinary.  Such,  however,  I 
conceive  to  be  the  circumstances  in  this  instance.  It  is  certainly  very 
extraordinary  that  a  few  gentlemen  of  acknowledged  skill,  but  whose 
means  and  appliances  are  concealed  from  no  one,  are  able  to  do  what 
nearly  the  whole  world  besides,  with  the  same  means,  acknowledges 
itself  unable  to  accomplish.  Such  is  the  fact  nevertheless ;  and  our 
lack  of  faith  in  their  testimony  is  only  a  necessary  result  of  our  expe- 
rience, and  of  the  experience  of  the  vast  majority  of  practical  surgeons, 
as  opposed  to  theirs. 

•  Op.  cit.,  p.  167. 

^  A  Treatise  on  Fractures  and  Luxations,  etc.,  Viy  P.  J.  Desault,  edited  bj  Xav. 
Bichat.     Amer.  ed.,  p.  251.     1805. 
3  Op.  cit.,  p.  223. 

^  Elements  of  Surgery,  by  Jolin  Syn»  Dorsey,  vol.  i.  p.  163.     Philadelphia,  1813. 
^  "Medical  Chronicle'"  of  Montreal,  vol.  i.  IN'o.  7,  1853. 

25 


402  FEACTUEES    OF    THE    FEMUE. 

I  might  properly  euough  dismiss  this  subject  with  no  further  argu- 
ment than  may  be  found  in  the  overwhelming  testimony  of  practical 
surgeons,  that  broken  femurs  do  in  their  experience  rarely  unite  with- 
out more  or  less  shortening;  but  I  cannot  avoid  calling  attention  to 
the  evidence  of  the  falsity  of  the  opposite  opinion,  which  is  furnished 
by  the  testimony  of  the  very  persons  who  themselves  claim  to  have 
obtained  such  fortunate  results. 

It  is  not,  as  might  have  been  supposed,  one  particular  form  of  dress- 
ing, which,  in  itself  peculiar,  and  more  perfect  than  all  others,  has  fur- 
nished these  results.  On  the  contrary,  the  plans  of  treatment  have 
been  constantly  unlike,  and  sometimes  quite  opposite.  Thus:  Desault 
used  a  straight  splint,  with  extension  and  counter-extension,  and  he 
refused  to  adopt  the  flexed  position  recommended  by  Pott,  because  his 
experience,  and  the  experience  of  other  French  surgeons,  had  taught 
him  its  inutility.^  Adopting  the  straight  position,  he  made  perfect 
limbs;  with  the  flexed  position,  he  found  it  impossible  to  do  so. 

Dorsey  used  the  splint  of  Desault,  as  modified  by  Physick  and  Hutch- 
inson. 

South,  whose  success  seems  to  have  been  equal  to  that  of  Desault 
or  Dorsey,  adopts  also  the  straight  position;  but  he  makes  no  perma- 
nent extension,  except  what  may  be  accomplished  through  the  medium 
of  four  long  side  splints  applied  after  "gentle"  extension  has  been  made 
by  the  assistants. 

Mr.  Amesbury,  on  the  other  hand,  made  perfect  limbs  only  with  his 
own  double  inclined  plane;  and  speaking  in  general  of  the  various 
plans  hitherto  contrived,  not  excepting  that  invented  by  Desault,  or 
the  method  practised  by  South,  which  had  already  been  recommended 
by  several  surgeons,  he  declares  that  "they  are  seldom  able  to  prevent 
the  riding  of  the  bone,  and  preserve  the  natural  figure  of  the  limb. 
Indeed,  so  commonly  does  retraction  of  the  limb  occur  under  the  use 
of  the  different  contrivances  usually  employed,  that  I  have  heard  a 
celebrated  lecturer  (now  retired)  in  this  town,  publicly  assert,  that  he 
never  saw  a  fractured  thigh-bone  that  had  united,  without  riding  of 
the  fractured  ends!"^  And  in  his  ^'■General  Inferences ^^'' \iq  uses  the 
following  emphatic  language:  "The  contrivances  which  are  commonly 
used  in  the  treatment  of  these  fractures  do  not  sufficiently  resist  the 
operation  of  the  forces  above  mentioned,  but  suffer  their  influence  to 
be  exerted  upon  the  bone,  in  all  cases  more  or  less  injuriously,  and  at 
the  same  time  often  assist  in  producing  displacement  of  the  fractured 
ends;  so  that  deformity,  differing  in  kind  and  degree  in  different  cases, 
is  almost  the  constant  result  of  fractures  of  the  femur  treated  by  these 
means."^ 

While  Mr.  Gam  gee,  a  writer  of  much  talent  and  industry,  thus 
broadly  contradicts  the  statements  of  Desault,  South,  Dorsey,  and 
Amesbury,  and  administers  a  severe  rebuke  even  upon  the  illustrious 
Liston:  "Pott's  plan,  the  long  splint,  M'Intyte,  and  their  modifica- 
tions, as  a  rule  entail  sensible  deformity,  which  in  many  cases  is  very 

'  Works  of  Desault.     Op.  cit.,  p.  225. 

*  Amesbury  on  Fractures,  &c.,  vol.  i.  p.  310.  3  Op.  cit.,  vol.  i.  p.  384. 


FEACTURES  OF  THE  SHAFT  OF  THE  FEMUR. 


403 


considerable.  It  is  a  significant  fact,  that,  though  the  example  esta- 
blished in  University  College  Hospital  by  the  late  Mr.  Liston,  of 
treating  fractures  of  the  thigh  by  the  long  splint  (Fig.  129),  and  of  the 
leg  by  the  modified  M'Intyre,  which  are  admitted  equal,  if  not  superior, 
to  other  splints,  was  rigidly  followed  in  that  institution,  the  patients 
admitted  with  broken  thighs  or  legs  were  frequently  discharged  with 
manifest  deformity,"^ 

Fig.  129. 


Liston's  method,  recommended  by  Samuel  Cooper,  Fergusson,  Pirrie,  and  otliers. 

With  how  much  force  his  own  remarks  as  to  the  experience  of  the 
University  College  Hospital  will  apply  to  the  starched  bandages  used 
by  himself,  the  reader  will  be  able  to  determine  when  referred  to  the 
opinion  of  Velpeau,  already  quoted,  who  claims  no  result  better  than 
an  average  shortening  of  half  an  inch.  It  is  true,  however,  that  M. 
Velpeau  prefers  and  advocates  the  starched  bandage,  but  it  is  not  true 
that  he  claims  to  be  able  to  prevent  a  shortening  of  the  bone. 

"What  other  modes  of  treatment  would  have  given  such  results?" 
This  question,  propounded,  no  doubt  honestly,  by  Mr.  Gamgee,  has 
here  its  fair  and  satisfactory  answer.  Almost  any  of  the  various 
modes  named;  for  if  we  must  receive  his  testimony,  we  are  equally 
bound  to  receive  the  testimony  of  Desault,  South,  Dorsey,  Amesbury, 
and  Scott.  If  we  give  credit  to  Mr.  Gamgee,  so  far  as  to  doubt  the 
statements  of  these  latter  as  to  the  degree  of  success  claimed  by  them, 
by  the  same  rule  we  must  doubt  his  own  statements  also,  as  to  the 
degree  of  success  claimed  by  himself.  This  I  say  with  all  sincerity 
and  kindness,  fully  believing  that  these  gentlemen  are  mistaken,  and 
not  that  they  intentionally  misrepresent  the  facts. 

By  a  reference  to  my  "Eeport  on  Deformities  after  Fractures,"  it 
will  be  seen  that  the  average  shortening  in  fractures  of  the  upper  third 
of  the  femur,  in  the  cases  examined  by  me,  was  about  four-fifths  of  an 
inch ;  in  the  lower  third  it  was  a  fraction  over  three-quarters,  and  in 
the  middle  third,  a  fraction  less  than  three-quarters  of  an  inch;  and 
the  average  of  the  whole  number  was  almost  exactly  three-quarters 
of  an  inch  (three-quarters  and  ■^\).  These  analyses  were  made  upon 
simple  fractures,  and  were  exclusive  of  those  in  which  no  shortening 
at  all  occurred.  An  analysis  which  included  also  those  which  had 
not  shortened,  reduced  the  average  shortening  to  half  an  inch  and 
about  one-tenth. 

An  examination  of  cabinet  specimens  does  not  present  a  result  so 


'  Advantages  of  the  Starched  Apparatus,  by  Joseph  Sampson  Gamgee. 
1853,  pp.  54,  55. 


London, 


404  FRACTUEES-  OF  THE  FEMUR. 

favorable  even  as  this.  Of  nineteen  fractures  of  the  shaft  of  the  femur 
contained  in  Dr.  Mutter's  cabinet,  not  one  seems  to  have  been  short- 
ened less  than  one  inch.  Specimen  B  63,  a  fracture  of  the  middle 
third,  is  united  with  a  shortening  of  two  inches  and  a  quarter ;  and 
specimen  B  130,  imperfectly  united  after  a  fracture  through  the  mid- 
dle third,  is  overlapped  three  and  a  half  or  four  inches. 

In  conclusion,  I  wish  to  say  briefly,  that  in  view  of  all  the  testimony 
which  is  now  before  me,  I  am  convinced — 

First.  That  in  the  case  of  an  oblique  fracture  of  the  shaft  of  the  femur 
occurring  in  an  adult,  whose  muscles  are  not  paralyzed,  but  which 
offer  the  ordinary  resistance  to  extension  and  counter-extension,  and 
where  the  ends  of  the  broken  bone  have  once  been  completely  dis- 
placed, no  means  have  yet  been  devised  by  which  an  overlapping  and 
consequent  shortening  of  the  bone  can  be  prevented. 

Second.  That  in  a  similar  fracture  occurring  in  children,  or  in  per- 
sons under  fifteen  or  eighteen  years  of  age,  the  bone  may  sometimes 
be  made  to  unite  with  so  little  shortening  that  it  cannot  be  detected 
by  measurement ;  but  whether  in  such  cases  there  is  in  fact  no  short- 
ening, since  with  children  especially  it  is  exceedingly  difficult  to 
measure  very  accurately,  I  cannot  say. 

Third.  That  in  transverse  fractures,  or  oblique  and  denticulated, 
occurring  in  adults,  and  in  which  the  broken  fragments  have  become 
completely  displaced,  it  will  generally  be  found  equally  impossible  to 
prevent  shortening;  because  it  will  be  found  generally  impossible  to 
bring  the  broken  ends  again  into  such  apposition  as  that  they  will  rest 
upon  and  support  each  other. 

Fourth.  That  in  all  fractures,  whether  occurring  in  adults  or  in 
children,  where  the  fragments  have  never  been  completely  or  at  all 
displaced,  constituting  only  a  very  small  proportion  of  the  whole 
number  of  these  fractures,  a  union  without  shortening  may  always  be 
expected. 

Fifth.  That  when,  in  consequence  of  displacement,  an  overlapping 
occurs,  the  average  shortening  in  simple  fractures,  where  the  best 
appliances  and  the  utmost  skill  have  been  employed,  is  about  three- 
quarters  of  an  inch. 

If  we  consider  the  muscles  alone  as  the  cause  of  the  displacement 
in  the  direction  of  the  long  axis  of  the  shaft,  the  shortening  of  the 
limb,  other  things  being  equal,  must  be  proportioned  to  the  number 
and  power  of  the  muscles  which  draw  upwards  the  lower  fragment. 
This  will  vary  in  different  portions  of  the  limb,  but  nowhere  will  this 
cause  cease  to  operate,  nor  will  its  variations  essentially  change  the 
prognosis. 

I  have  not  intended  to  say  that  other  causes  do  not  operate  occa- 
sionally in  the  production  of  shortening,  but  only  that  muscular  con- 
traction is  the  cause  by  which  this  result  is  chiefly  determined,  and 
that  its  power  will  be  ordinarily  the  measure  of  the  shortening. 

Treatment. — All  the  early  surgeons,  so  far  as  we  know,  adopted 
the  straight  position  in  the  treatment  of  fractures  of  this  bone;  either 
with  simple  lateral  splints,  or  with  long  splints,  with  or  without  exten- 
sion, or  with  only  rollers  and  compresses,  or  with  extension  alone. 


FEACTUEES  OF  THE  SHAFT  OF  THE  FEMUR. 


405 


Such  was  the  unanimous  opinion  and  practice  of  surgeons  nntil 
about  the  middle  of  the  last  century,  at  which  time  Percival  Pott  wrote 
his  remarkable  treatise  on  fractures,  a  work  distinguished  for  the  origi- 
nality and  boldness  of  its  sentiments,  and  which  was  destined  soon  to 
revolutionize  the  old  notions  as  to  the  treatment  of  fractures,  and  to 
establish  in  their  stead,  at  least  for  a  time,  what  has  been  called,  not 
inappropriately,  the  "physiological  doctrine;"  the  peculiarity  of  which 
doctrine  consisted  in  its  assumption  that  the  resistance  of  those  muscles 
which  tend  to  produce  shortening  can  generally  be  sufficiently  over- 
come by  posture,  without  the  aid  of  extension,  and  that  for  this  pur- 
pose, for  example,  in  the  case  of  a  broken  femur,  it  was  only  necessary 
to  flex  the  leg  upon  the  thigh,  and  the  thigh  upon  the  body,  laying  the 
limb  afterwards  quietly  on  its  outside  upon  the  bed. 

Very  few  surgeons,  even  of  his  own  day,  ever  gave  in  their  full  ad- 
Fig.  130. 


Double  inclined  plane  employed  in  Middlesex  Hospital,  London. 

hesion  to  the  exclusive  physiological  system  as  taught  and  practised 
by  Pott  himself,  but  multitudes,  especially  among  the  English,  adopted 
in  general  his  views,  only  choosing  to  place  the  patients  upon  their 


Fis;.  131. 


Amesbury's  splint. 
Fig.  132. 


Amesbury's  splint  applied. 


40(>  FRACTURES    OF    THE    FEMUR. 

backs  rather  than  upon  their  sides,  and  laying  the  limbs  flexed  over  a 
double  inclined  plane.  (Fig.  130.)  To  the  support  of  this  system  of 
Pott's,  thus  modified,  Sir  Astley  Cooper,  0.  Bell,  John  Bell,  Earle, 
White,  Sharp,  and  Amesbury  (Figs.  131,  132),  lent  the  influence  of 
their  great  names,  and  its  triumph,  so  far  as  the  judgment  of  British 
surgeons  was  concerned,  soon  became  complete. 

In  France,  and  upon  the  continent  generally,  the  reception  of  this 
system  was  more  slow  and  reluctant ;  but  Dupuytren  now  for  once 
taking  ground  with  his  great  rival,  Sir  Astley,  adopted  almost  without 
qualification  these  novel  views.  The  decision  of  Dupuytren  deter- 
mined the  opinions  of  a  large  portion  of  the  continental  surgeons; 
and  had  it  not  been  for  the  early  and  decisive  opposition  of  Desault 
and  Boyer  (Fig.  133),  the  great  surgeon  of  St.  Bartholomew  might 
have  continued  for  a  long  time  to  have  enjoyed  a  triumph  upon  the 
continent,  and  perhaps  throughout  the  world,  equal  to  that  which  had 
already  been  decreed  to  him  in  Great  Britain. 

Fig.  133. 


Boyer's  splint. 

On'  this  side  of  the  Atlantic,  the  practice  of  Pott,  at  least  in  so  far 
as  it  applied  to  the  treatment  of  fractures  of  the  thigh,  never  gained 
a  distinguished  advocate  ;  and  but  few  ever  adopted  the  practice  as 
modified  by  White,  Amesbury,  Bell,  A.  Cooper,  &c. 

But  whatever  may  have  been  the  early  success  of  these  doctrines, 
either  here  or  elsewhere,  it  is  certain  that  a  strong  reaction  has  taken 
place,  and  that  gradually,  in  all  parts  of  the  world,  the  opinions  of 
practical  surgeons  have  been  settling  back  into  their  old  channel.  It 
would  be  difficult  to  find  to-day,  in  France,  a  dozen  distinguished  sur- 
geons who  adopt  universally  the  flexed  position  in  the  treatment  of 
fractures  of  the  femur;  and  in  England  the  reaction  is,  if  possible, 
even  more  complete. 

In  my  tour  of  1844,  during  which  I  visited  very  many  of  the  hos- 
pitals of  Great  Britain  and  upon  the  continent  of  Europe,  I  do  not 
remember  to  have  seen  the  flexed  position  once  employed  in  the  treat- 
ment of  a  broken  thigh;  and  I  shall  presently  show  that  the  straight 
position  is  at  the  present  moment  very  generally  adopted  by  the  best 
American  surgeons. 

There  have  been,  then,  three  grand  epochs  in  the  history  of  the 
treatment  of  fractures  of  the  thigh. 

First.  That  in  which  the  straight  position  was  universally  adopted, 
and  which  reaches  from  the  earliest  periods  to  the  period  of  the  writ- 
ings of  Pott,  or  to  about  the  middle  of  the  last  century. 

Second.  The  epoch  of  the  flexed  position,  which,  inaugurated  by 
Pott,  had  already  begun  to  decline  at  the  beginning  of  the  present 
century,  and  which  may  be  said  to  have  been  completed  within  less 
than  one  hundred  years  from  the  date  of  its  first  announcement. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR.      407 

Third.  The  epoch  of  the  restoration,  or  that  in  which  surgeons,  bj 
the  vote  of  an  overwhelming  majority,  have  declared  again  in  favor 
of  the  straight  position.     This  is  the  epoch  of  our  own  day. 

Although  American  surgeons  have  generally  adopted  the  straight 
splint  in  the  treatment  of  fractures  of  the  thigh,  yet  the  form  and 
construction  of  the  splint  have  been  greatly  varied.  The  simple  long 
splint  of  Desault  and  the  more  complicated  apparatus  of  Boyer  (Fig. 
133),  have  each  their  advocates;  but  it  is  seldom  that  we  meet  with 
these,  or  with  any  of  the  other  forms  of  apparatus  originally  employed 
in  foreign  countries,  without  noticing  that  they  have  been  subjected 
to  considerable  modifications ;  indeed,  most  of  the  straight  splints  as 
well  as  double-inclined  planes  in  use  at  present  among  American  sur- 
geons, may  farily  be  regarded  as  original  inventions. 

Kathan  Smith,  of  New  Haven  ;^  Nathan  R.  Smith,  of  Baltimore^ 
(Fig.  134);  Nott,  of  Mobile^  (Fig.  136);  McNaughton,  of  Albany,'*  and 
Valentine  Mott,  of  New  York,  are  the  only  American  surgeons  of 

Fig.  134. 


Nathan  E.  Smith's  suspending  apparatus,  or  double  inclined  plane. 

distinguished  reputation,  and  with  whose  practice  I  am  familiar,  who 
recommend  exclusively  the  double-inclined  plane;  and  perhaps  we 
have  a  right  to  infer  from  the  following  paragraphs,  copied  from  a  let- 
ter addressed  to  the  author  a  year  or  two  since,  that  the  opinions  of 
Dr.  Mott  have  undergone  some  modification  in  view  of  the  improve- 
ments recently  made  in  the  construction  of  straight  splints,  and  in 
the  means  of  extension  and  counter-extension. 

"  Many  years  since  I  introduced  into  the  New  York  Hospital 
Boyer's  long  splint,  and  continued  to  use  it  there,  and  in  private 
practice,  for  a  long  time.  I  found,  however,  in  many  cases,  that  I 
had  more  or  less  trouble  at  the  foot  and  groin  from  the  points  of  ex- 
tension and  counter-extension.  I  then  gradually  laid  it  aside,  and  for 
some  years  have  again  taken  up  the  double  inclined  plane. 

"From  the  abundance  which  I  have  seen,  I  am  free  to  say  that,  if  I 

'  Amer.  Med.  Rev.  Published  at  Philadelphia,  1825,  vol.  ii.  p.  355.  Also  Medical 
and  Surgical  Memoirs  of  Nathan  Smith.     Published  at  Baltimore,  pp.  129-141. 

^  Med.  and  Surg.  Memoirs,  pp.  143-162.  See  also  Geddings,  Baltimore  Med.  and 
Surg.  .Journ.,  vol.  i.  1833  ;  and  Sargent's  Minor  Surgery,  p.  171. 

^  Amer.  Journ.  Med.  Sciences,  vol.  xxiii.  p.  21. 

*  Trans.  Amer.  Med.  Assoc,  vol.  x.  p.  317.     Rep.  on  Defor.  after  Frac. 


408 


FEACTURES    OF    THE    FEMUR. 


had  my  own  femur  broken,  I  would  be  treated  upon   the  double 
inclined  plane. 

Fig.  135. 


B.  Welch's  Thigh  Apparatus. 

a.  Upper  extremity,  broad  and  well  cushioned  so  as  to  rest  easily  over  against  the  side  of  the  body. 
6  Brace  for  fixing  a  joint ;  to  be  used  only  in  packing,  c.  Screw  for  adjusting  a  sliding  joint,  for  the  pur- 
pose of  lengthening  or  shortening  the  splint,     d.  The  thumb-screw  for  making  extension. 

The  hollow  splints  suspended  below  can  be  moved  upon  each  other  by  a  joint  opposite  the  ham,  and 
their  position  secured  by  a  movable  bar.  They  may  also  be  lengthened  or  shortened.  There  is  a  joint 
corresponding  to  the  heel,  and  another  opposite  the  sole  of  the  foot. 

This  apparatus  may  be  used  as  a  double  inclined  plane,  or  as  a  straight  splint.  Lateral  splints  accom- 
pany the  apparatus,  all  of  which  are  made  of  gutta  percha  veneered  with  mahogany. 

Fig.  136. 


JosiAH  C.  Nott's  Double  Inclined  Plane. 
In  this  apparatus  the  limb  is  secured  to  the  splint  by  vertical  pins  and  leather  straps  ;  the  upper  sur- 
face of  the  thigh  splint  is  carved  out  a  little,  to  fit  the  thigh ;  the  two  portions  are  articulated  by  a  joint 
like  that  of  a  carpenter's  rule,  and  this  joint  may  be  steadied  by' a  horizontal  bar  underneath.     For  the 
rest,  the  drawing  sufficiently  explains  itself. 

"  The  Drs.  Burges,  Brothers,  Court  St.,  Brooklyn,  Long  Island,  have 
made  an  improvement  upon  the  extended  principle  (Figs.  137,  138). 
Their  apparatus  is  now  complete,  and  is.  in  use  at  the  Bellevue  Hos- 
pital, where  I  advised,  some  time  since,  that  it  should  be  tried.  It 
has  succeeded  admirably  in  two  cases." 

While,  on  the  other  hand,  among  the  advocates  of  the  straight  splint 
are  found  the  names  of  Physick,^  Dorsey,^  Gibson,^  Horner,^  J.  Harts- 
horne,'  H.  H.  Smith,^  Neill,'  R.  Coates,^  H.  Hartshorne,^  Norris,^" 
Gross.^^ 

'  Elements  of  Surgery,  by  .John  Syng  Dorsey.     Philadelphia,  1813,  p.  175. 

2  Ibid. 

^  Institutes  and  Practice  of  Surgery,  by  Wm.  Gibson,  6th  edit.,  vol.  i.     Phila. 

''  Treatise  on  the  Practice  of  Surgery,  by  Henry  H.  Smith.     Phila.,  1856. 

6  Ibid.  6  Ibid. 

"^  Philadelphia  Med.  Examiner.     October,  1855. 

^  Amer.  Journ.  Med.  Sciences,  vol.  xx.  p.  18. 

^  Trans.  Amer.  Med.  Assoc,  vol.  v.     Rep.  on  Deg.  after  Frac. 

'»  Ibid.  "  Ibid. 


FKACTUEES  OF  THE  SHAFT  OF  THE  FEMUE.      409 
Fig.  137. 


Buege's  Apparatus. 
Pig.  138. 


Burqe's  Apparatus  applied. 

"^.  Thick  mattress.  B.  Thin  mattress.  C  Wooden  platform  upon  which  the  thiu  mattress  is  laid. 
This  platform  is  made  in  two  pieces  and  hinged  together  so  as  to  fold  upon  itself  for  couvenieace  of  trans- 
portation, and  when  in  use  is  merely  hooked  upon  the  central  platform  D. 

"  D.  Central  or  cushioned  platform  supported  at  either  end  by  wooden  strips  marked  E,  which  rests 
upon  F.  A  second  platform  of  same  extent  as  B.  This  constitutes  a  shelf  for  the  bed  pan,  which  may 
be  introduced  below  from  either  side. 

"  G.  Hair  cushion,  upon  which  the  hips  of  the  patient  rest.  This  cushion,  as  well  as  the  platform  D, 
to  which  it  is  buttoned,  has  a  semicircular  oj)ening  at  its  lower  margin  for  convenience  of  defecation. 

"  H.  A  rectangular  wooden  slide,  exactly  corresponding  to  its  fellow  upon  the  opposite  side  of  the 
pelvis.  These  slides  are  so  arranged  upon  the  platform  D  as  to  be  separated  or  approximated  at  will, 
and,  by  a  thumb-screw  which  passes  through  a  fissure  in  the  hoi-izontal  portion  of  each,  they  may  be 
fixed  at  the  desired  point  so  as  exactly  to  embrace  the  pelvis  of  any  patient.  There  is  also  a  fissure  in 
the  perpendicular  portion  of  each  rectangular  slide,  and  a  screw  passing  through  the  same.  One  of  these 
is  to  secure  the  upper  end  of  the  long  splint  J,  and  the  other  for  the  attachment  of  a  short  splint  J,  upon 
the  side  of  the  pelvis  corresponding  to  the  uninjured  limb.  Both  of  these  splints  are  well  padded  upon 
one  surface  and  may  be  elevated  or  depressed  at  will,  in  order  to  bring  them  to  the  level  of  the  limbs, 
and  fixed  at  the  proper  attitude  by  the  screws  already  mentioned.  They  are  also  mutually  transferable, 
thus  adapting  the  apparatus  to  fractures  of  either  thigh. 

"  /SS.  Counter-extending  pads.  These  are  attached  by  leather  straps  to  the  upper  surface  of  the  plat- 
form D,  about  twelve  inches  apart.  Passing  under  the  cushion  G,  and  becoming  well-rounded  pads,  they 
traverse  the  tuberosities  of  the  ischia,  pass  between  the  thighs  and  thence  perpendicularly  to  the  hori- 
zontal iron  rod  or  crossbar  L.  The  crossbar  L  is  supported  at  each  end  by  a  perpendicular  bar  extend- 
ing upwards  from  the  platform  D.  Attached  by  one  extremity  to  the  crossbar  L,  is  a  rod  P,  running 
parallel  with  and  situated  directly  above  the  thigh.  The  other  end  of  this  rod  P,  is  supported  by  an 
arched  iron  bar  N,  extending  upwards  from  the  outer  side  of  the  long  splint  J.  The  rod  P  is  designed  to 
afford  special  support  to  the  injured  limb  whenever  such  support  is  deemed  advisable.  Two  or  three 
strips  of  cotton  cloth,  of  suitable  width,  may  be  passed  around  the  limb,  either  internally  or  externally 
to  the  splints  of  coaptation,  and  tied  over  the  supporting  rod  P.  Splints  of  coaptation  are  to  be  applied 
according  to  the  exigencies  of  the  case. 

"  M.  An  inside  splint  covered  by  the  bandages.  Q.  The  screw  by  which  extension  is  effected  in  the 
ordinary  way,  having  at  one  extremity  a  swivel  and  hook  tied  to  a  strip  of  wood  in  the  loop  of  adhesive 
plaster  below  the  foot." 


410 


FEACTUEES    OF    THE    FEMUE. 


Says  Dr.  Gross:  "Many  years  ago,  before  I  had  much  experience  in 
this  class  of  injuries,  I  occasionally  employed  the  flexed  position,  but 
I  soon  found  that  it  was  objectionable,  on  account  of  the  great  difficulty 
in  maintaining  so  accurate  apposition  of  the  ends  of  the  fragments.  Of 
late  years  I  have  confined  myself  entirely  to  the  use  of  the  straight 
position,  and  I  have  never  had  any  cause  to  regret  it.  In  the  adult,  I 
sometimes  employ  the  apparatus  of  Desault,  as  modified  by  Physick, 
but  much  more  frequently  one  of  my  own  construction,  somewhat 
upon  the  principle  of  that  of  Dr.  Neill,  described  in  the  Philad^l'phia 
Medical  Examiner  for  1855.  I  have  used  it  for  nearly  twenty  years, 
and  it  has  generally  answered  the  purpose  most  admirably  in  my 
hands.  It  consists  simply  of  a  box  for  the  thigh  and  leg,  with  a  foot- 
piece,  and  two  crutches,  one  for  the  axilla  and  the  other  for  the  peri- 
neum, to  make  the  requisite  extension  and  counter-extension.  With 
such  an  apparatus,  an  oblique  fracture  of  the  thigh  can  be  treated  with 
great  comfort  to  the  patient,  and  with  the  assurance  of  a  good  limb. 
In  children,  I  have  effected  some  excellent  cures  simply  by  means  of 
a  sole  leather  trough,  well  padded  and  provided  with  a  foot-piece. 

"The  great  objection  to  the  flexed  position  is  the  difficulty  of  keep- 
ing the  ends  of  the  broken  bones  in  apposition;  the  upper  one  having 
a  constant  tendency  to  pass  awaj'  from  the  inferior.  Other  objections 
might  be  urged  against  the  flexed  position,  but  this  is  quite  sufficient 
to  induce  me  to  reject  it."^ 

Dr.  Neill,  of  Philadelphia,  has  contrived  a  very  ingenious  mode  of 
making  both  extension  and  counter-extension  at  the  same  moment,  by 
means  of  a  twisted  rope  which  is  fastened  by  its  two  ends  respectively, 
to  the  perineal  band  above  and  the  extending  bands  below  (Fig.  139). 

Fig.  139. 


John  Neill's  Straight  Thigh-Splint. — Extension  and  counter-extension,  made  at  the  same  moment. 

Dr.  Charles  Ap.  Bowen,  of  St,  Catherine's,  C.  W.,  has  sought  also  to 
accomplish  the  same  purpose  by  another  method;  but  which  will  be 
best  understood  by  a  reference  to  the  accompanying  drawing  (Fig.  140). 
The  projection  of  the  foot-piece  on  both  sides  of  the  splint  is  intended 
to  give  additional  security  to  the  splint,  and  to  render  the  instrument 
applicable  to  either  the  right  or  left  limb. 

'Trans.  Am.  Med.  Assoc,  vol.  x. ;  also  System  of  Surg.,  by  S.  D.  Gross,  1859,  p.  221. 


FRACTUEES  OF  THE  SHAFT  OF  THE  FEMUR. 
Fig.  140. 


411 


Charles  Ap.  Bowen's  Thigh-Splint. 
a.  Splint  composed  of  two  thin  pieces  of  board  screwed  together.  6.  Brass  band.  c.  Sliding  bar,  for 
increasing  the  length  of  the  splint,  d.  Crutch-head,  with  slots  for  counter-extending  bands,  e.  Trans- 
verse grooves  in  sliding  bar.  /.  Eccentric  roller,  which,  being  turned  by  its  handle  g,  is  made  to  fasten 
itself  in  the  transverse  grooves  and  secure  the  sliding  bar.  h.  Foot-piece  with  slots  for  extending  bands 
on  one  side,  and  for  counter-extending  bands  on  the  other,  i.  Screw,  j.  Martingale  counter-extension 
straps,  k.  Pin  which  holds  the  screw  in  place.  By  taking  out  the  pin  k,  the  screw  and  the  foot-piece 
can  be  removed,  and  then  the  whole  apparatus  may  be  packed  in  a  very  small  space. 

J.  F.  Flagg's  thigh  apparatus,  as  used  in  the  Massachusetts  General 
Hospital,  bj  Warren,  Bigelow  and  others  (Figs.  141  to  149  inclusive). 


Fig.  141. 


Fig.  142. 


Pelvic  belt,  and  perineal  straps. 


Foot-piece  and  screw. 


Fig.  143. 


Lateral  view  of  the  apparatus,  without  the  belt. 


Fig.  144. 


Front  view,  with  folded  sheet  laid  across. 


412 


FRACTURES    OF    THE    FEMUR. 
Fig.  145. 


Apparatus  applied. 
Fig.  146. 


f^ii  fpTtM'^W^'f^'J^  »'i    tl 


Side  view  of  apparatus  applied. 
Fig.  147. 


Fig.  148. 


Figs.  147,  148.     Mode  of  making  extension  with  adhesive  plaster. 

"The  belt  is  made  of  strong  webbing,  hav- 
ing pockets  on  each  side,  to  receive  the  long 
splint.  It  is  also  furnished  with  straps  and 
buckles.  The  perineal  strap  (Fig.  149),  corre- 
sponding to  the  injured  side,  is  kept  constantly 
buckled,  while  the  other  may  be  occasionally 
loosened,  or  left  off,  as  its  purpose  is  only  to 
steady  the  apparatus.  Where  the  straps  pass 
under  the  perineum,  they  are  covered  with 
wash-leather.  Before  applying  the  belt,  a 
pillow-case  or  two  may  be  passed  around  the 
waist.  The  padlock  is  only  to  be  used  in  case 
the  patient  persists  in  unbuckling  the  straps. 
The  splints  being  applied,  with  also  short  side 
splints,  junks,  containing  bran  or  sand,  &c.,  are  to  be  secured  more 
firmly  to  the  limb  by  bands  of  webbing  and  buckles." 


Perineal  baud   secured  with  a 
padlock. 


FRACTUEES  OF  THE  SHAFT  OF  THE  FEMUR. 


413 


150. 


3a 


The  two  Warrens,  father  and  son,  of  Boston,  Kimball,  of  Lowell, 
Sanborn,  of  Lowell,  Mass.,  Mussey,  of  Cincinnati,  Ohio,  J.  B.  Flint,  of 
Louisville,  Kj,,  Armsbj,  of  Albany,'  also  recom- 
mend some  form  of  the  straight  splint.     Says  Dr. 
Mussey : — 

"  For  all  fractures  of  the  thigh-bone,  I  employ 
the  extended  position  of  the  limb.  There  are  but 
few  cases  in  which  extending  force  is  not  neces- 
sary to  prevent  the  degree  of  deformity  or  short- 
ening which  would  occur  without  it.  Of  thirty 
specimens  of  fracture  of  the  shaft,  in  my  collec- 
tion, only  two  are  transverse.  In  fractures  of  the 
neck,  especially  with  old  subjects,  I  sometimes 
avoid  the  application  of  any  kind  of  apparatus  for 
permanent  extension ;  but  in  all  cases,  whether  of 
the  neck  or  shaft,  where  such  extension  is  at- 
tempted, I  have  found  the  straight  position  of  the 
limb  to  be  the  most  reliable." 

And  Dr.  Kimba"ll,  who  employs  generally,  San- 
born's splint  (Fig.  150),  uses  the  following  em- 
phatic language : — 

"If  I  should  be  asked  under  what  circumstances 
I  would  use  the  double  inclined  plane  in  case  of 
fracture  of  the  femur,  I  would  unhesitatingly  an- 
swer, never!  I  have  long  since  abjured  the  dou- 
ble inclined  plane  in  every  form  of  fracture  of  this 
bone,  finding  the  straight  splint  fully  adequate  to 
all  purposes  for  which  any  apparatus  of  this  kind 
is  required.  In  support  of  this  statement,  I  could 
furnish  a  great  number  of  cases  showing  that  the 
locality  of  the  fracture,  the  importance  of  which 
is  so  much  dwelt  upon  in  the  books,  constituted, 
in  no  case,  a  valid  objection  to  it  use." 

Extension  in  Sanborn's  apparatus  is  effected  by 

means  of  adhesive  straps,  and  counter-extension 

by  a  perineal  band ;  but  the  patient  may  at  any 

moment  relieve  the  pressure  in  the  perineum  by 

esting  his  axilla  upon  the  head  of  the  crutch. 

Daniell,  of  Savannah,  Georgia,  recommends  the 
straight  position,  the  limb  being  laid  in  a  kind  of 
long  box,  and  the  extension  being  made  with  a 
weight  and  pulley.^     Dugas,  of  Augusta,  Georgia,  employs  the  pulley 
and  weight  also,  but  uses  the  long  side  splint  instead  of  the  box.^ 

Says  Dr.  Dugas :  "  Suitable  compresses  having  been  placed  upon 
the  thigh,  apply  over  them  four  wooden  splints  a  little  shorter  than 
the  femur  (one  in  front,  one  in  the  rear,  and  one  on  either  side). 


Sasbors's  Splint,  a.  The 
movable  crutch,  h.  The 
screw  which  fixes  the 
crutch,  c.  The  crossbar, 
to  which  the  ends  of  the 
strap  are  fastened,  d.  The 
moving  screw. 


'  Trans.  Am.  Med.  Assoc.,  vol.  x.     Report  on  Deformities  after  Fractures. 
^  Amer.  Joum.  Med.  Sciences,  vol.  iv.  p.  330,  1829. 
^  Soutliern  Med.  and  Surg.  Journ.     Feb.  1854. 


414: 


FEACTURES    OF    THE    FEMUB. 
Fig.  151. 


L.  A.  Dugas'  method.     The  long  splint  omitted  because  it  would  mask  the  drawing 


152. 


Illvistrates  Dugas'  mode  of  securing  the 
weight  without  fatigue  to  the  ankle- 
joint. 


and   secure   these   with   many-tailed   bandages   or  with   single  ties. 

A  two  or  three  pound  weight  should 
then  be  fixed  to  the  foot  and  hung  over 
the  foot-board  of  the  bed,  as  indicated  in 
the  annexed  figures  (Figs.  151,  152),  so  as 
to  keep  up  extension,  while  the  resistance 
of  the  patient's  body  will  effect  counter- 
extension.  A  splint  four  inches  wide,  and 
extending  from  the  side  of  the  thorax  to 
a  little  below  the  foot,  will  now  serve  to 
keep  the  limb  straight  and  to  maintain 
the  foot  in  a  proper  position.  This  splint 
should  be  secured  by  separate  ties  passed 
around  the  abdomen,  pelvis,  thigh,  leg, 
and  foot.  Finally,  an  arch  of  crossed  hoops  should  protect  the  toes 
from  the  bedclothes." 

Joshua  B.  Flint,  of  Louisville,  Ky.,  has  sometimes,  as  will  be  seen 
by  the  following  quotation  from  a  letter  addressed  to  the  author,  em- 
ployed a  similar  apparatus  with  excellent  results. 

"  Of  late  years  I  have  generally  employed  Liston's  single  long  splint; 
having  it  thickly  padded,  and  then  applying  a  roller  from  the  foot  to 
the  hip,  in  such  a  manner  as  to  secure  the  limb  firmly  to  the  splint. 
This  is  about  the  only  case  in  which  I  now  wrap  a  fractured  limb  with 
a  roller."         *  ^  *  *  *  *  * 

"I  have  repeatedly  used,  and  with  much  satisfaction,  extension  by 
means  of  the  pulley,  having  the  co-operation  only  of  short  lateral 
splints  at  the  place  of  the  fracture.  With  a  mattress  slightly  inclined 
toward  the  head,  and  moderate,  but  persistent  traction  made  on  the 
injured  limb  by  a  weight  made  fast  to  the  foot  by  means  of  a  cord 
passing  over  a  pulley — the  pulley  being  secured  to  the  foot-board — I 
have  conducted  some  tolerably  oblique  fractures  to  a  satisftactory  ter- 
mination, and  with  much  more  comfort  to  the  patients  than  attends 
any  other  equally  effectual  method  of  extension." 

Wm.  E.  Horner,  of  Philadelphia,  employed  a  long  outside  splint 
(Fig.  153,  a),  extending  into  the  axilla,  and  padded,  so  as  to  avoid  the 
necessity  of  junks;  with  fenestrse,  for  extending  and  counter-extending 
bands;  and  also  a  foot-piece;  and  a  short  inside  splint  (6),  made  to 
extend  from  the  perineum  to  the  bottom  of  the  foot.     Across  the  ex- 


FEACTUEES    OF    THE    SHAFT    OF    THE    FEMUE.  415 

Fig.  153. 


"W.  E.  Horner's  thigh-splint. 

cavated  upper  end  of  this  splint,  a  strip  of  leather  is  stretched  to 
receive  the  pressure  of  the  perineum,  while  the  perineal  band  is  made 
to  pass  through  two  firm  leather  loops  on  the  outside  of  the  splint. 

Dr.  Joseph  E.  Hartshorne,  of  Philadelphia,  rejected  the  perineal 
band  altogether,  and  sought  to  make  the  counter-extension  by  means 
of  the  internal  long  splint  alone;  and  for  this  purpose,  he  cushioned 
the  head  of  the  inside  splint,  as  will  be  seen  in  the  accompanying  draw- 
ing (Fig.  lo-i).    The  head  of  the  outside  splint  may  also  be  cushioned. 

Fig.  154. 


Joseph  Hartshorne's  thigh-spliut. 


but  not  for  the  purpose  of  employing  it  as  a  means  of  counter-exten- 
sion. The  outside  splint  is  so  adjusted  to  the  foot-piece,  that  it  may 
be  removed,  in  case  of  a  compound  fracture,  without  disturbing  either 
the  extension  or  counter-extension.* 

The  accompanying  drawings  (Fig.  155,  1,  2,  3,  4),  representing  a 
very  simple  and  easily-constructed  apparatus  devised  by  Dr.  Alonzo 
Chapin,  of  Massachusetts,  has  many  points  of  real  excellence.^  It  will 
serve  at  least  to  instruct  the  reader  how  he  may  furnish  himself  extem- 
poraneously with  a  complete  apparatus  when  he  is  not  otherwise  pre- 

Fig.  155. 


o  c 

::ai 

^: 

— — — 

gTtiI 

Alonzo  Chapin's  thigh  apparatus. 

'  Treatise  on  the  Practice  of  Surgery,  by  Henry  H.  Smith.. 
*  Amer.  Journ.  Med.  Sci.,  April,  1851,  p.  355. 


Ibid. 


416  FRACTURES  OF  THE  FEMUR. 

pared.  The  iron  screw  and  swivel  for  making  extension  can  be  made 
by  any  blacksmith  in  a  few  minutes.  Dr.  Chapin  uses  two  of  these 
screws,  but  one  would  ordinarily  answer  the  purpose  equally  well. 
By  having  the  tenons  in  the  side  splints  instead  of  in  the  foot-piece, 
the  apparatus  may  be  opened  laterally  and  made  to  fit  the  sides  of  the 
limb  more  or  less  closely. 

There  are  many,  however,  of  our  most  distinguished  surgeons,  who 
retain  the  flexed  position  in  certain  fractures,  such  as  an  oblique 
downward  and  forward  fracture,  occurring  just  below  the  trochanter 
minor,  and  a  similar  fracture  just  above  the  condyles,  or  in  certain 
cases  of  fractures  in  children,  or  in  very  old  people,  but  who,  never- 
theless, give  a  decided  preference  to  the  straight  splint  in  those  oblique 
fractures  of  the  shaft  which  constitute  by  far  the  greatest  proportion 
of  all  these  accidents.  Among  these,  I  will  mention  the  names  of 
Post,  of  New  York,^  De  Lamater,  of  Cleveland,  Ohio,^  Pope,  of  St. 
Louis,  Mo.,^  Knight,  of  New  Haven,^  and  Eve,  of  Nashville,  Tenn.^ 

Dr.  Pope  has  given  us  his  views  upon  this  subject  very  much  at 
length : — 

"  In  the  treatment  of  fractures  of  the  femur,  I  employ  neither  the 
straight  nor  the  flexed  position  exclusively,  but  the  one  or  the  other, 
according  to  the  site  of  fracture.  If  the  fracture  involves  either  the 
upper  (below  the  trochanter  minor)  or  the  lower  third  (above  the  con- 
dyles) of  the  femur,  I  make  use  of  the  double  inclined  plane  of  Sir 
Charles  Bell.  If,  on  the  other  hand,  the  seat  of  fracture  be  in  the 
middle  third  of  the  thigh,  I  greatly  prefer  the  straight,  long  splint  of 
Mr.  Liston. 

"  My  reasons  are  briefly  the  following :  In  fractures  below  the  tro- 
chanter minor,  the  upper  fragment  is  tilted  forwards  and  upwards,  by 
the  unrestrained  action  of  the  psoas  muscle,  so  that  no  extension  in 
the  straight  direction  will  avail  to  draw  down  the  upper  in  a  line  with 
the  lower  portion  of  the  lever. 

"  The  same  thing  results  in  fractures  of  the  lower  third,  but  in  op- 
posite directions.  Here  the  heel  becomes  the  fixed  point,  and  the  , 
gastrocneraii  draw  the  lower  fragment  backwards  and  downwards,  4 
whilst  the  upper  fragment  projects  in  front.  Rectilinear  extension 
can  no  more  correct  the  malposition  of  the  lower  fragment  in  this  case, 
than  it  can  in  the  former  that  of  the  upper.  But  in  both  (upper  and 
lower  third  fractures),  by  placing  the  limb  over  a  double  inclined 
plane,  these  otherwise  insuperable  deviations  of  the  fragments  are 
prevented,  and  the  whole  bone  is  brought  into  proper  line. 

"  When,  on  the  contrary,  the  fracture  implicates  the  middle  third 
or  even  the  middle  half  of  the  femur,  I  invariably  employ  the  straight 
splint,  which  I  regard  as  by  far  the  simplest,  most  effectual,  and  best 
means  of  treatment;  and,  indeed,  but  for  the  reasons  assigned,  I  should 
only  be  too  glad  to  use  it  exclusively  in  the  management  of  all  frac- 
tures of  the  thigh. 

"  My  cabinet  presents  several  specimens  of  broken  femurs,  which 
illustrate  the  soundness  of  these  views :  in  which  the  abnormal  direc- 

'  Trans.  Amer.  Med.  Assoc,  vol.  x.  ;  Rep.  on  Def.,  etc. 


FRACTUEES    OF    THE    SHAFT    OF    THE    FEMUR.  417 

tion  of  the  fragments  alluded  to  as  occurring  in  fractures  of  tlie  upper 
and  lower  thirds,  is  very  marked ;  the  deformities  having  resulted 
from  treatment  in  the  straight  position.  So  far  as  function  and  sym- 
metry are  concerned,  the  lower  deformity  is  altogether  the  most  serious. 
The  unseemly  projection  above  the  knee,  the  unnatural  exposure  in 
front  of  the  articular  surfaces  of  the  condyles,  which  are  not  set  bluffly 
on  those  of  the  tibia,  together  with  the  altered  site  of  the  patella,  and 
the  diminished  power  of  the  quadriceps  muscle,  both  weaken  and 
deform  the  joint, 

"  With  regard  to  the  management  of  fractures  below  the  trochanter 
minor,  or  at  other  points  of  the  femur,  by  means  of  the  double  in- 
clined plane,  I  am  well  aware  of  the  diflQculty  of  properly  confining 
the  pelvis,  but  this  objection  I  am  far  from  considering  as  insuperable. 
So,  too,  the  outward  tendency  of  the  upper  fragment,  caused  by  the 
gluteus,  may  be  humored  by  carrying  the  limb  off  at  an  oblique  angle 
to  the  axis  of  the  body. 

"  It  is,  perhaps,  needless  to  add,  that  in  fractures  of  the  condyles, 
of  the  inter-trochanteric  portion,  as  well  as  of  the  neck  of  the  femur 
(when  osseous  union  is  attempted),  whether  within  or  without  the 
capsule,  I  likewise  give  preference  to  the  straight  position." 

The  practice  of  Dr.  Pancoast,  of  Philadelphia,  is  peculiar,  and  will 
be  best  described  by  himself. 

"I  treat  all  thighs,  fractured  in  their  middle  part,  by  the  long  splint, 
and  in  the  straight  position.  In  fractures  occurring  at  either  end  of 
the  bone,  I  resort  at  first  to  the  angular  splint  and  the  flexed  position, 
and  thus  place  the  muscles  more  at  rest;  in  which  position,  also,  there 
is  less  tendency  to  angular  displacement  and  shortening.  After  the 
lapse  of  a  few  days,  when  the  disturbed  muscles  have  lost  their  ten- 
dency to  spasm,  and  the  hardened  cellular  tissue  about  the  fracture 
has  formed  a  sort  of  bond  between  the  ends  of  the  broken  bone,  I 
gently  bring  the  limb  down  to  the  straight  position,  and  apply  the 
long  splint."^ 

The  practice  of  treating  fractures  of  the  thigh,  as  well  as  all  other 
fractures  of  the  long  bones,  with  the  roller  alone,  and  without  either 
lateral  splints  or  extending  apparatus,  first  suggested  by  Eadley,  has 
found  in  this  country  but  one  distinguished  advocate.  Dr.  Dudley,  of 
Lexington,  Ky.^  Nor,  with  all  my  respect  for  that  venerable  and  truly 
great  surgeon,  can  I  persuade  myself  that  the  practice  is  able  to  accom- 
plish, in  a  majority  of  cases,  the  indications  proposed,  nor  indeed  that 
it  is,  at  least  in  the  hands  of  inexperienced  surgeons,  wholly  safe.  Dr. 
D.,  of  Aberdeen,  Miss.,  has  reported  to  me  one  example  in  which,  after 
the  application  of  this  bandage,  by  a  pupil  of  Dr.  Dudley's,  to  a  negro 
slave,  who  had  a  fracture  of  the  femur,  death  of  the  limb  ensued,  and 
amputation  became  necessary.  The  negro  was  sixteen  years  old,  and 
healthy ;  the  fracture  was  caused  by  the  fall  of  a  tree  or  of  a  branch, 
and  was  simple.  The  bandage  was  applied  from  the  toes  upwards  to 
the  groin,  and  was  not  opened  for  several  days,  at  which  time  the 

'  Trans.  Am.  Med.  Assoc,  vol.  x.     Rep.  on  Def.,  etc. 

2  Amer.  Journ.  of  the  Med.  Sci.,  vol.  xix.  p.  270  ;  Transylvania  Journal,  April,  1836 ; 
Boston  Med.  and  Surg.  Journ.,  vol.  xxxiv.  p.  35. 

27 


418  FRACTURES    OF    THE    FEMUR, 

whole  limb  was  found  to  be  in  a  state  of  dry  gangrene,  with  the 
exception  of  the  upper  two-thirds  of  the  thigh,  which  was  swollen 
enormously,  and  partially  gangrenous  as  high  up  as  the  groin. 

Dr.  D.  says:  "  Having  heard  the  history  of  the  case  carefully  stated, 
observing  the  leg  and  the  lower  part  of  the  thigh  to  be  in  a  state  of 
dry  gangrene,  and  seeing  the  marks  of  the  bandage  visibly  impressed 
on  the  surface,  my  opinion  was  made  up  at  the  time  that  the  gangrene 
had  resulted  from  pressure  of  the  bandage.  The  femoral  artery  at  the 
groin  was  in  a  sound  and  natural  state,  and,  if  I  mistake  not,  after  the 
limb  was  removed,  it  was  traced  to  the  point  of  obliteration  where  the 
gangrene  commenced,  and  where  the  impression  of  the  bandage  was 
observed;  thus  far,  I  think,  it  was  of  natural  size  and  calibre.  Hence 
the  conclusion  is  inevitable,  that  the  death  of  the  limb  resulted  from 
the  pressure  of  the  bandage,  and  not  of  one  of  the  fragments.  It  was 
a  curious  specimen  of  dry  mortification,  and  I  regret  that  I  did  not  use 
the  means  of  preserving  it.  I  was  then  engaged  in  a  very  laborious 
practice,  thirty  miles  from  home,  on  horseback,  and  consequently 
could  not  conveniently  spare  the  time  to  attend  to  it  as  an  object  of  sur- 
gical curiosity.  Dr.  H.  and  myself  cut  into  the  leg  in  various  places 
in  order  to  examine  the  muscles,  arteries,  nerves,  etc.,  but  found  the 
integuments  so  hard  that  it  was  really  difficult  to  penetrate  them  with 
a  knife ;  the  resistance  to  the  knife  was  more  like  that  of  dry  hickory 
wood  than  anything  else."^ 

In  relation  to  other  plans  of  treatment,  I  shall  content  myself  by 
declaring  my  belief  that  the  starched  bandage  of  Suetin,  Yelpeau, 
Gamgee,  and  others,  cannot  be  regarded  as  a  safe  or  effectual  appara- 
tus ;  and  that  extension  alone,  without  either  side  splints  or  long  splints, 
which  I  have  seen  practised  by  Jobert,  of  Paris,  and  other  French  sur- 
geons occasionally,  is  inefficient.  My  remarks  hereafter  will  therefore 
be  confined  to  a  more  full  declaration  of  the  principles  involved  in, 
and  the  proper  mode  of  using,  the  long  splint. 

Without  limiting  ourselves  to  the  consideration  of  any  one  of  the 
special  forms  of  apparatus,  we  may  say  that  the  following  ought  to  be 
regarded  as  essential  elements  in  the  construction  of  the  long  straight 
splint  (Fig.  162):  Length  sufficient  to  extend  at  least  several  inches 
above  the  ala  of  the  pelvis,  and  the  same  distance  below  the  foot;  such 
thickness  as  that  it  shall  be  firm  and  unyielding;  width  sufficient  to 
make  it  serve  as  one  of  the  lateral  splints,  since  over  all  the  more  pro- 
perly called  lateral  splints  it  possesses  this  advantage,  that  it  can  never 
become  displaced  downwards  or  upwards;  its  width  ought  seldom  to 
be  less  than  three  and  half  inches,  nor  should  its  width  diminish  as  it 
descends  toward  the  foot,  as,  in  consequence  of  this  construction,  the 
roller,  which  is  intended  to  secure  the  limb  to  the  splint,  has  a  con- 
stant tendency  to  slide  in  the  same  direction. 

A  foot-piece,  or  transverse  block  to  which  the  foot  may  be  attached 
for  the  purpose  of  making  extension  as  nearly  as  possible  in  the  axis 
of  the  limb.  If  this  foot-piece  is  movable,  it  will  serve  only  the  single 
purpose  above  mentioned,  and  no  rule  need  govern  its  width.     But  in 

'  For  a  more  complete  account  of  this  interesting  case,  see  Buffalo  Med.  Journ.,  vol. 
xiv.  p.  193,  Sept.  1858. 


FEACTURES    OF    THE    SHAFT    OF    THE    FEMUR.  419 

this  case  there  must  be  another  block  attached  to  the  bottom  of  the 
long  splint,  at  a  right  angle  with  the  shaft,  and  of  the  same  width  as 
the  splint;  the  object  of  which  will  be  to  support  and  steady  the  side 
splint,  and  to  prevent  its  rolling  inwards  or  outwards.  Where  this  is 
neglected,  frequent  disturbance  of  the  broken  fragments,  and  a  de- 
formity from  inclination  of  the  foot  outwards  or  inwards,  are  apt  to 
ensue.  If  the  foot-piece  is  not  movable,  then  it  may  be  of  the  same 
width  as  the  side  splint,  and  serve  both  to  steady  the  side  splint  and 
as  a  means  of  extension.  The  length  of  the  foot-piece  ought  not  to 
be  such  as  to  interfere  with  a  long  inner  splint,  in  case  its  use  should 
be  deemed  advisable.  With  two  fenestrse  placed  at  the  upper  part  of 
the  splint,  for  the  reception  of  the  counter-extending  band,  the  long 
outside  splint  is  now  complete. 

These  are,  so  to  speak,  its  simple  elements,  and  compose  the  splint 
in  its  rudest  form,  without  which  no  splint  can  be  perfect,  yet  upon 
which  many  real  improvements  may  be  based.  Thus,  it  must  be  re- 
garded as  an  improvement  to  have  the  splint  so  constructed  as  that  it 
may  be  readily  lengthened  or  made  shorter,  to  accommodate  itself  to 
the  size  of  the  patient;  or  that  the  foot-piece  should  be  furnished  with 
a  screw,  for  the  purpose  of  making  the  extension  more  uniformly ;  or 
that  the  same  mode  of  operating  should  apply  also  to  the  counter- 
extension. 

The  adhesive  plaster  bands  are  beyond  all  comparison  the  best  means 
of  making  a  permanent  extension  which  are  at  present  known  to  sur- 
geons. Hitherto,  one  of  the  most  serious  difficulties  in  the  way  of 
extension,  and  the  objection  which  has  been  most  effectively  urged 
against  its  adoption,  has  been  the  excoriations,  ulcerations,  and  even 
sloughing,  which  so  often  occurred  from  the  use  of  the  various  extend- 
ing bands  about  the  ankle.  This,  together  with  the  injuries  occasion- 
ally inflicted  by  the  perineal  band,  has  been  regarded  by  other  sur- 
geons than  Dr.  Mott,  whose  opinion  we  have  already  quoted,  as  a 
sufficient  reason  for  preferring  the  flexed  position.  But  no  one  who 
has  employed  the  adhesive  plaster  extending  bands  will  doubt  that, 
so  far  as  injuries  to  the  foot  and  ankle  are  concerned,  this  objection  is 
now  entirely  disposed  of.  It  is  adopted  in  many,  perhaps  most  of  the 
American  hospitals,  and  in  no  case  where  it  has  been  employed  have 
I  known  the  slightest  excoriations  to  have  been  produced.  I  regard 
this  simple  invention,  therefore,  as  one  of  the  most  important  im- 
provements in  the  treatment  of  fractures  of  the  thigh,  and  it  is  not 
surprising  that  several  claimants  have  appeared  for  the  original  sug- 
gestion. By  Dr.  Brinton  it  has  been  claimed  for  Dr.  Ellerslie  Wallace, 
of  Philadelphia ;'  and  by  Dr.  Sargent  for  Dr.  Gross,  of  the  same  city  f 
while  by  American  surgeons  generally  the  invention  has  been  con- 
ceded to  Dr.  Josiah  Crosby,  of  New  Hampshire,  to  whom  certainl}'-  is 
due  the  credit  of  having  brought  it  into  notice,  if  not,  indeed,  of  the 
first  suggestion.^ 

'  Note  to  first  American  edition  of  Erichsen's  Surgery,  p.  225. 

^  Note  to  3d  American  edition  of  Miller's  Practice  of  Surgery,  p.  653.  See  also  N. 
Y.  Med.  Gaz.,  vol.  iv.  p.  87. 

■*  See  case  reported  in  N.  H.  .Tourn.  of  Med.,  for  1851 ;  also,  N.  Y,  Journ.  of  Med.,  vol. 
vi.  2d  series,  p.  137.     See  also,  Trans.  Amer.  Med.  Assoc,  vol.  iii.  p.  382. 


420  FRACTURES    OF    THE    FEMUR. 

The  mode  of  using  adhesive  plaster  for  extension  is  briefly  as  fol- 
lows : — 

A  single  band,  long  enough  to  extend  from  a  point  just  below  the 
knee  to  twelve  or  sixteen  inches  beyond  the  foot,  and  about  three 
inches  wide,  is  to  be  applied  along  each  side  of  the  leg.  Instead  of 
one  band  on  each  side,  two  may  be  employed ;  which  shall  traverse 
each  other  somewhat  obliquely,  so  that  one  band  shall  fall  a  little  in 
front  of  the  malleolus  and  one  a  little  behind.  Having  wrapped  the 
whole  circumference  of  the  ankle,  including  the  malleoli  and  heel,  in 
a  heavy  pledget  of  cotton,  laid  underneath  the  adhesive  bands,  a  roller 
is  now  to  be  applied  from  the  toes  upwards  as  far  as  the  knee,  and 
secured  with  a  little  flour  paste  or  starch.  Before  fastening  the  bands 
to  the  foot-block,  each  band  should  be  twisted  into  a  rope  below  the 
foot ;  and  to  prevent  any  degree  of  lateral  pressure  upon  the  sides  of 
the  ankle  and  foot,  already  tolerably  protected  by  the  cotton,  a  piece 
of  thin  board,  longer  than  the  width  of  the  ankle,  and  notched  at  each 
extremity,  should  be  placed  between  the  bands  below  the  bottom  of 
the  foot. 

The  attempt  to  use  the  adhesive  plaster  also  as  a  perineal  band,  for 
the  purpose  of  making  counter-extension,  does  not  seem  to  have  been 
equally  successful,  unless  I  except  the  experience  of  that  very  excellent 
surgeon.  Dr.  David  Gilbert,  of  Philadelphia,  and  of  one  or  two  other 
gentlemen  mentioned  by  him,  whose  practice  I  will  presently  describe 
more  particularly.  For  my  own  part  I  never  could  succeed  to  any 
purpose  with  these  bands  in  the  perineum,  or  at  least  no  better  than 
with  the  ordinary  perineal  bands;  and  I  very  much  fear  that,  notwith- 
standing the  ingenious  contrivances  of  my  friend  Dr.  Gilbert,  we  have 
still  to  incur  the  risk  of  ulcerations,  &c.,  from  this  portion  of  our 
dressings;  fortunately,  however,  the  perineal  band  never  completely 
ligates  the  limb,  and  it  has  rarely,  therefore,  been  found  so  mischievous 
as  the  ordinary  extending  bands  at  the  ankle.^  In  the  fracture  appa- 
ratus lately  invented  by  the  Burges,  the  peculiar  mode  of  action  of 
the  perineal  band,  avoiding,  as  it  does,  pressure  upon  the  front  of  the 
groin,  diminishes  still  further  this  danger ;  and  in  the  construction  of 
my  own  splint,  I  have  long  had  regard  to  the  importance  of  this 
principle  by  attaching  the  anterior  portion  of  the  perineal  band  to  an 
upright  crutch-head,  which  is  made  to  rise  more  or  less  from  the  top 
of  the  splint,  according  to  the  size  or  obesity  of  the  patient.  In 
Burges'  and  Lente's  apparatus  this  principle  is,  however,  most  fully  re- 
cognized, and  the  indication  is  most  completely  accomplished. 

I  will  take  this  occasion  to  mention  that  with  large  fat  people,  I 
have  sometimes  found  it  necessary  to  dispense  with  the  perineal  band 
altogether,  and  in  such  cases  I  have  succeeded  very  well  in  making 
counter-extension  by  lifting  the  foot  of  the  bed  one  or  two  feet,  and 
trusting  alone  to  the  weight  of  the  body. 

Dr.  Gilbert,  as  I  have  already  stated,  believes  also  that  the  adhe- 
sive plaster  may  be  employed  as  successfully  in  making  counter- 
extension  as  in  extension.     He  published  his  first  case  of  treatment 

'  For  cases  of  sloughing,  &c.,  from  perineal  band,  see  N.  Y.  Journ.  of  Med.,  vol. 
xvi.,  2d  ser.,  p.  261,  March,  1856  ;  also  same  journal,  Jan.  1840,  p.  239. 


FEACTUEES  OF  THE  SHAFT  OF  THE  FEMUE. 


421 


by  this  metliod  in  the  American  Journal  of  Medical  Science  for  1851, 
and  since  then  he  has  used  it  in  every  case  of  fracture,  not  only  of 
the  thigh,  but  of  the  leg,  as  he  affirms,  with  the  happiest  results,  Drs. 
Kerr,  Kenderdine,  and  Hunt,  of  Pennsylvania,  who  have  also  adopted 
Dr.  Gilbert's  method,  speak  of  it  in  terms  of  commendation.  In  the 
first  of  the  accompanying  wood-cuts  (Fig.  156)  nothing  is  intended  to 
be  shown  but  the  long  splint  and  the  adhesive  straps  employed  in 
extension  and  counter-extension.  It  will  be  seen  also  that  Dr.  Gilbert 
employs  the  ordinary  tourniquet  of  Petit  for  the  purpose  of  making 
the  extension.  The  "pelvic  band"  is  a  broad  strip  of  adhesive  plaster, 
and  serves  to  bind  down  the  perineal  bands  more  closely  to  the  skin. 
If  necessary,  additional  strips  of  adhesive  plaster  may  be  applied,  and 
in  order  to  increase  their  strength  they  may  be  doubled.^ 

In  compound  fractures  Dr.  Gilbert  recommends  a  modification  of 
the  common  fracture  box  (Fig.  158).  In  this  apparatus  the  foot-board 
is  omitted,  and  a  block  for  the  reception  of  the  frame  of  the  tourniquet  is 
substituted.  Each  side  of  the  box  consists  of  three  separate  segments. 
Of  these  the  upper  and  lower  are  permanently  screwed  to  the  bottom- 
Fig.  356. 


D.  Gilbert's  mode  of  making  ConNTER-EXTENsiON,  and  Extension. 
1.  Anterior  and  posterior  counter-extending  adhesive  bands,  two  and  a  half  inches  wide,  crossing  each 
other  before  they  pass  through  the  mortise  holes.     2.  The  same,  crossing  at  the  upper  part  of  thigh  and 
perineum.     3.  Horizontal  pelvic  band,  which  may  be  three  inches  wide.    4.  Extending  bands,  receiving 
strap  of  tourniquet  in  the  hollow  of  the  foot.     5.  Tourniquet. 

Fig.  157. 


Gilbert's  Apparatus  applied  in  a  Case  op  Fracture  of  both  Thighs. 
1,  1.  Anterior  adhesive  counter-extending  strips.     2.  Distal  extremity  of  posterior  adhesive  strip  of 
left  side.     3.  Adhesive  strip  surrounding  pelvis,  binding  the  anterior  and  posterior  strips  to  pelvis.    4. 
Inner  extremity  of  the  extending  adhesive  strip,  forming  stirrup  under  the  foot  to  receive  the  strap  of 
the  tourniquet.     5.  Cicatrix  of  left  thigh.     7,  7.  Petit's  tourniquet,  by  which  the  power  was  applied. 


'  Gilbert,  Amer.  Journ.  Med.  Sci.,  April,  1859,  pp.  410-424. 


422 


FEACTUEES    OF    THE    FEMUE. 


board,  and  the  central  one  is  attached  by  hinges.  By  this  arrangement 
there  is  full  access  to  the  wound,  which  may  be  dressed  from  day  to 
day  without  disturbing  the  extension  and  counter-extension,  maintained 
by  the  permanently  attached  upper  and  lower  segments. 

Fig.  158. 


Gilbert's  Box  for  CoMPonND  Fractures  op  the  Thish. 
1.  The  four  counter-extending  adhesive  strips,  as  if  encircling  the  knee  and  upper  part  of  leg. 
The  two  extending  adhesive  strips  crossing  at  the  bottom  of  the  foot,  ready  to  be  applied  to  the  foot. 
Tourniquet. 


Lente,  of  Cold  Spring,  N.  Y.,  has  also  occupied  himself  with  the 
invention  of  an  apparatus  by  which  he  hopes,  in  some  measure  at 
least,  to  obviate  the  usual  inconveniences  of  the  perineal  band.  The 
apparatus  described  by  him  possesses  also  many  other  peculiarities,  and 
such  as  demand  for  it  especial  attention.  I  shall,  therefore,  permit 
him  to  explain  to  the  reader  its  several  parts  in  his  own  language. 
Speaking  of  the  different  forms  of  the  straight  splint,  he  remarks  : — 

"The  pressure  of  the  counter-extending  band  upon  the  groin  has 
always  been  the  stumbling  block  of  this  apparatus.  Desault  saw  the 
advantage  of  making  the  tuberosity  of  the  ischium  the  point  d^appui, 
but  failed,  as  we  have  seen,  in  his  attempt  to  do  so;  and  various  sur- 
geons have  since  contrived  as  many  different  plans  for  effectually 
carrying  out  his  idea,  but  without  complete  success.  No  one,  how- 
ever, has  approached  this  nearer  than  the  Burges.  However,  the  fact 
seems  to  be  that  neither  the  groin  nor  the  tuberosity  is  fitted  to  bear 
alone  the  pressure  of  the  counter-extension  in  cases  of  considerable 
shortening,  and  therefore  of  great  tension  in  the  application  of  the 
extending  power. 

"  It  is  therefore  my  object,  in  the  further  modification  of  the  New 
York  Hospital  apparatus,  to  distribute  the  pressure  on  these  two 
points;  and  further,  in  order  to  render  the  pressure  on  the  groin  safer 
and  more  comfortable,  and  also  to  remove  all  pressure  from  the 
muscles,  vessels,  nerves,  &c.,  of  the  thigh  in  front,  I  propose  to  add 
an  iron  brace  (A,  Fig.  159),  extending,  in  a  curved  form,  from  the  upper 
end  of  the  external  splint  directly  across  the  body  to  the  median  line, 
and  cushioned  on  its  inner  surface  as  represented  in  the  engraving. 
Sliding  on  this,  and  furnished  with  a  binding  screw  to  fix  it  at  any 
required  point,  is  a  plate,  P,  to  the  lower  part  of  which  is  attached  a 
buckle  for  securing  the  anterior  extremity  of  the  perineal  band.  By 
this  arrangement,  I  am  enabled  to  make  the  direction  of  the  counter- 
extending  force  of  this  portion  of  the  band  correspond  to  the  axis  of 
the  limb,  instead  of  oblique ;  and,  furthermore,  it  allows  me  to  dis- 
pense with  all  that  portion  of  the  outer  splint  between  the  crest  of  the 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR.      423 

ilium  and  the  axilla ;  thus  reducing  it  to  the  original  length  of  De- 
sault,  obviating  the  constriction  of  the  chest  by  the  body-band,  and 
producing  a  less  irksome  confinement  of  the  upper  part  of  the  body. 
In  lieu  of  the  body-band,  there  is  a  pelvic  strap  extending  from  the 
end  of  the  iron  brace,  to  the  movable  plate  of  which  it  is  secured  by 
buckles,  around  the  back  to  the  top  of  the  splint,  thus  binding  the 
apparatus  firmly  to  the  pelvis,  if  found  necessary.  It  should  be  men- 
tioned that  the  brace  is  so  attached  to  the  splint,  through  the  ingenuity 
of  Mr.  Tiemann,  surgical  instrument  maker,  of  New  York,  as  to  allow 
of  its  being  shifted  to  either  side  according  as  the  fracture  is  on  the 
right  or  left,  or  of  being  removed  for  packing.  He  has  also  made  the 
long  splint  in  two  portions  sliding  on  each  other  so  as  to  shorten  or 
lengthen  it  according  to  the  size  of  the  patient,  and  to  facilitate  its 
package  and  transportation.  Desault  attached  the  posterior  as  well  as 
the  anterior  extremity  of  the  perineal  band  to  the  long  splint ;  but  it 
will  be  found  that,  by  so  doing,  he  does  not  grasp  with  it,  as  he  in- 
tended, the  tuberosity;  on  the  contrary,  when  extension  is  applied,  it 
slips  under  it  or  above  it,  and  is  thus  almost  totally  ineffectual  in 
relieving  the  groin.  To  be  effective,  it  should  be  attached  to  the 
splint  at  a  point  considerably  lower  down  ;  and  it  is  necessary  that 
the  medium  of  attachment  should  be  movable,  in  order  that,  when 
the  upper  end  of  the  splint  is  placed  opposite  the  crista  ilii,  it  may  be 
shifted,  if  necessary,  a  trifle  upwards  or  downwards,  that  the  band  may 
exactly  grasp  the  tuberosity.    I  therefore  provide  a  button  (B,  Fig.  159), 

Fig.  159. 


secured  by  a  thumb-screw,  and  several  holes  at  different  contiguous 
points  in  the  splint,  to  which  it  may  be  shifted  with  facility.  The 
posterior  end  of  the  perineal  band  is  either  passed  under  the  outer 
splint  and  buttoned,  as  shown  at  B,  Fig.  159,  or  carried  between  the 
cushion  and  splint,  over  the  top  of  the  latter  to  the  button,  as  indi- 
cated at  E,  Fig.  160.  The  latter  arrangement  is  applicable  especially 
to  fat  and  muscular  subjects,  particularly  females,  who  have  an  abun- 
dance of  fat  and  other  tissues  covering  the  tuberosity,  which  might 
allow  the  band  to  slip  by  the  bone,  unless  attached  in  this  manner.  I 
propose,  also,  to  attach  both  the  extending  and  counter-extending 
bands  to  the  apparatus  through  the  medium  of  elastics.  Upon  sug- 
gesting this  to  Mr.  Tiemann,  I  found  that  some  one  had  anticipated 
me  with  regard  to  the  extending  band  ;  and  Mr.  T.  has  arranged  a 
strong  spiral  spring  in  the  ferule  of  the  screw,  which  supplies  the 


424 


FRACTUEES    OF    THE    FEMUE. 
Fig.  160. 


place  of  the  elastic  at  that  point.  It  is  absolutely  necessary  that  the 
elastics  attached  to  the  perineal  band,  which  may  be  of  India  rubber, 
should  be  very  short,  an  inch  or  so,  and  very  strong;  otherwise,  they 
will  give  too  much  to  the  extending  force,  and  had  better  be  dispensed 
with  entirely.  These  elastics  are  intended  to  fulfil  two  indications ; 
first,  to  render  the  pressure  more  tolerable  to  the  patient,  as  elastics 
always  do;  secondly,  to  keep  up  an  equable  and  uninterrupted  trac- 
tion on  the  muscles  of  the  thigh,  thus  tending  still  further  to  diminish 
the  shortening,  and  to  counteract  the  effect  of  any  stretching  or  yield- 
ing in  any  part  of  the  apparatus.  In  order  to  render  the  pressure  of 
the  perineal  band  still  less  unpleasant,  and  less  likely  to  cause  excori- 
ation of  the  groin,  it  might  be  of  service  to  apply  several  coatings  of 
a  mixture  of  collodion  25  parts,  castor  oil  1  part,  which  has  been 
found  to  form,  in  other  parts  of  the  body,  and  might  form  here  a 
smooth  and  enduring  cuticle. 

"  My  remaining  modification  of  the  splint  is  a  foot-piece  (D,  Fig.  159), 
attached  by  a  slide  and  thumb-screw  to  the  mortise  in  the  external 
splint,  and  capable  of  removal  at  pleasure.  This  is  intended  to  obvi- 
ate two  inconveniences  of  the  old  arrangement;  first,  to  prevent  a 
tendency  to  eversion  of  the  foot,  which  almost  always  exists,  some- 
times to  a  great  extent ;  and,  secondly,  by  projecting  a  little  beyond 
the  toes,  to  take  off  the  pressure  of  the  bedclothes,  which  tends  still 
further  to  evert  the  foot,  and  is,  besides,  exceedingly  uncomfortable 
to  the  patient.  In  Fig.  160  this  arrangement  is  dispensed  with,  and 
its  place  supplied  by  a  foot-piece  (C),  which  also  obviates  the  neces- 


FEACTUEES    OF    THE    SHAFT    OF    THE    FEMUE.  425 

sity  for  the  block  for  preserving  the  parallelism  of  the  adhesive  bands, 
since  these  bands  pass  from  the  leg,  on  either  side,  around  this  piece, 
binding  firmly  to  the  sole  of  the  foot.  The  cords  connecting  it  with 
the  screw  are  so  arranged  as  to  draw  uniformly  on  this,  so  as  not  to 
tilt  it  against  the  *  ball'  of  the  foot.  By  resting  below  the  heel  on 
the  mattress,  it  serves  to  support  the  weight  of  the  clothes,  and  also 
prevents  eversion  of  the  foot.  This  contrivance  is  an  imitation  of 
Boyer's,  and  may,  by  some  surgeons,  be  preferred;  although  it  is,  in 
my  opinion,  not  so  efficient  as  the  foot-piece  (D,  Fig.  159),  (F)  is  a 
wedge-shaped  cushion,  very  useful  in  maintaining  the  whole  appa- 
ratus in  a  level  position,  and  taking  oft'  the  pressure  from  the  heel 
and  tendo  Achillis.  An  inside  splint,  extending  from  the  perineum  to 
the  inner  malleolus,  and  a  guttered  splint  for  the  upper  and  lower 
surfaces  of  the  thigh  respectively,  with  suitable  cushions  for  the 
splints,  complete  this  apparatus." 

Following  the  suggestion  made  by  Dr.  NeilV  who  uses  for  this  pur- 
pose a  Spanish  windlass,  I  have  had  the  foot-block  of  my  own  splint 
(Fig.  161)  so  constructed  as  that  counter-extension  may  be  made  at  the 
same  moment  with  the  extension.  The  principle  is  the  same  as  that 
employed  in  the  ancient  "glossocomon,"  described  by  most  of  the  early 
surgical  writers.  The  advantages  of  this  method  are  that  the  counter- 
extension,  as  well  as  the  extension,  can  be  made  slowly,  steadily,  and 
firmly ;  the  patient  cannot,  if  disposed  to  interfere  with  the  dressings, 
loosen  or  disturb  them ;  the  limb  is  acted  upon  equally  in  each  direc- 
tion, and  the  rollers  which  secure  the  limb  to  the  splint  do  not  be- 
come drawn  obliquely  and  disarranged  by  the  daily  attempts  to 
increase  or  continue  the  extension.  The  only  danger  is,  that,  in  the 
hands  of  inexperienced  surgeons,  too  much  force  will  be  applied,  and 
perineal  ulcerations  ensue. 

In  constructing  the  perineal  band,  I  now  usually  adopt  the  suggestion 
made  to  me  some  time  since  by  Dr.  Boardman,  of  this  city.  A  sheet 
of  foolscap,  or  the  half  of  a  newspaper  is  folded  into  a  ribbon  of  about 
one  inch  and  a  half  in  width ;  this  is  intended  to  give  firmness  to  the 
perineal  band,  and  to  prevent  its  corrugation.  The  surface  which  is 
to  be  laid  against  the  skin  is  then  covered  with  cotton  wadding,  and 
the  whole  enveloped  in  a  long,  narrow  strip  of  cotton  cloth,  and 
neatly  stitched.  The  strip  of  cotton  cloth  must  be  much  longer  than 
the  padded  portion  of  the  band,  in  order  to  tie  through  the  fenestras. 
Before  securing  the  band  in  place,  a  strip  of  patent  lint  should  be 
laid  in  the  perineum  with  its  soft  side  against  the  skin.  This  may 
be  occasionally  renewed. 

With  children  I  often  employ  only  the  simple  splint  figured  in  Fig. 
162,  yet  if  the  little  patient  is  restless  and  disposed  to  throw  himself 
about  the  bed,  I  prefer  the  double  splint  shown  in  Fig.  163,  to  which 
is  attached  a  screw  of  peculiar  construction,  called  the  "endless  screw," 
(Figs.  164, 165,  166, 167),  the  pattern  for  which  was  sent  to  me  by  some 
gentleman  in  Boston,  whose  name,  I  regret  to  say,  I  cannot  now  recall. 

It  will  be  found  necessary,  generally,  to  confine  both  limbs  to  the 

'  Philadelphia  Med.  Exam.,  vol.  xi.  p.  579. 


426 


FEACTUEES    OF    THE    FEMUE. 


Fig.  161. 


The  AUTHOK  s  Single  Steaight  Thigh-Splint,  for  Children  or  ABULTS.-a.  Crutch-head,  .vith  two 
rings  for  the  passage  of  the  perineal  band,  b,  b.  Upper  sliding  portion  of  the  splint,  c.  Eatchet  to  secure 
the  «PP-  portion  of  the  splint  when  drawn  out.  d,  d.  Lower  sliding  portion  of  the  splint,  to  which  is 
attached  the  foot-block,  e.  Foot-block,  which,  with  the  lower  sliding  portion  of  the  splint,  ci  is  moved 
upwards  or  downwards  by  the  screw,  /.  g.  Brass  ring  fastened  to  the  outer  end  of  the  foot-block.  The 
perineal  band  having  passed  through  the  rings  in  the  crutch-head,  is  made  fast  to  this  ring-  so  that 
when  the  foot-block  descends,  extension  and  counter-extension  are  made  at  the  same  moment  h  Cross 
piece,  to  steady  the  long  splint. 

Fig.  162. 


The  Ahthor's  Single  Straight  Thigh-Splint,  for  Children,  or  the  straight  splint  in  its  simplest  and 
elementary  form.  °       t-  i-  cci  ouu. 

Fig.  163. 


The  Author's  Double  Straight  Thigh-Splint,  for  Children  or  AruLTS.-Both  of  the  lon^  splints  arP 
laid  outside  of  the  two  thighs.  ^  spnnts  ai  e 


Fig.  164. 

© 
© 

®     O     © 

Fig.  165. 


Fig.  167. 


SCALE  ONE-FOURTH  OF  FULL  SIZE. 

Endless  Screw,  used  by  the  Author  for  making  Extension  in  the  Double  Straight  Splint  -Fig 
164.  Front  view.  Fig.  165.  Side  view.  Fig.  166.  End  view  ;  a  is  a  screw  working  in  a  toothed  wheel,  b. 
Fig.  167.  Front  removed,  showing  the  plane  part  of  toothed  wheel  for  extension  strap,  c,  c  Two  small 
screws  to  fasten  extension  strap. 

long  side  splints  with  rollers,  over  junks,  the  rollers  being  carefully  ap- 
plied from  the  foot  to  the  groin.  In  this  vvaj  alone  can  children  be  pre^ 
vented  from  constantly  disturbing  the  dressings.  When  thus  secured 
these  patients  become  completely  manageable,  and  can  be  readily  moved 
at  any  time  from  the  bed  to  a  lounge  or  even  into  the  open  air. 

In  all  cases  one  should  prefer  to  use  side  splints,  carefully  fitted  • 


FEACTUEES    OF    THE    SHAFT    OF    THE    FEMUE. 


427 


Fig.  168. 


the  whole,  both  side  and  long  splints,  being  applied  to  the  limb  over 
neatly-made  cotton  pads  or  junks,  of  which  there  ought  to  be  laid 
upon  every  part  of  the  leg  and  thigh  as  many  as  may  be  necessary  to 
prevent  unequal  pressure. 

I  am  especially  careful  to  place  a  thick  but  soft  pad  underneath  the 
knee,  since  if  this  is  not  done  the  forced  extension  into  which  the 
hamstrings  are  thrown  soon  becomes  irksome  and  even  painful.  A 
thick  compress  ought  also  to  be  placed  under  the  back  of  the  leg,  just 
above  the  heel,  to  prevent  the  weight  of  the  limb  from  producing 
ulceration. 

To  this  general  plan  of  treatment  now  recommended  for  fractures  of 
the  femur  the  writer  makes  no  exceptions,  unless  it  be  in  the  case  of  a 
fracture  of  the  neck  of  the  femur  occurring  in  very  old  persons,  or  in 
fractures  just  above  the  condyles,  where  the  direction  of  the  fracture 
is  obliquely  downwards  and  forwards;  in  the  former  of  which  often 
no  rule  can  be  adopted,  except  that  the  patient  should  be  placed  in 
that  position  which  may  be  found  most  comfortable;  and  in  the  latter 
of  which  the  flexed  position  seems  indeed  the  most  rational,  yet,  ac- 
cording to  the  evidences  furnished  by  Malgaigne,  its  advantages  over 
the  straight  position  are  far  from  being  established.  In  fractures  occur- 
ring just  below  the  trochanter  minor,  my 
own  experience  agrees  with  that  of  the 
distinguished  author  just  quoted,  that 
the  straight  position  is  still  the  best ;  an 
experience  which  seems  to  me  also  to 
admit  of  a  satisfactory  explanation.  It 
is  not  directly  upwards,  but  rather  out- 
wards and  upwards  (Fig.  168),  that  the 
lower  end  of  the  proximal  fragment  is 
thrown  by  the  action  of  the  psoas  magnus 
and  iliacus  internus,  so  that  in  order  to 
meet  the  supposed  indication  it  will  be 
necessary  to  carry  the  lower  part  of  the 
limb  outwards  also,  a  position  which 
would  certainly  be  found  very  inconve- 
nient, if  not  actually  impracticable,  in 
the  majority  of  cases. 

Nor  can  the  tendency  of  the  upper 
fragment  to  rise,  and  consequently  to 
separate  from  the  lower,  be  effectually 
met  by  posture  alone,  unless  the  thigh 
is  completely  flexed  upon  the  body ;  a 
position,  again,  which  will  be  found  in- 
convenient, if  not  impossible. 

It  is  apparent,  therefore,  that  by  posture  alone  we  can  only  very 
imperfectly  accomplish  an  approximation  of  the  fragments ;  while,  in 
adopting  the  flexed  position,  we  have  almost  entirely,  whatever  may 
be  said  to  the  contrary,  deprived  ourselves  of  the  means  of  extension 
and  counter-extension.  On  the  other  hand,  admitting  that  by  the 
straight  position  we  have  momentarily  provoked  a  resistance  which 


428 


FBACTUEES    OF    THE    FEMUE. 


flexion  of  the  limb  might  have  prevented,  we  shall  be  able,  slowly  but 
effectually,  to  overcome  this  resistance  by  steady  and  continued  exten- 
In  the  one  case  we  have  made  a  present  gain,  but  a  fiaal  loss; 


sion. 


and  in  the  other  a  present  loss  results  in  our  final  gain.  So  it  is  that 
experience  has  shown  in  more  than  one  case  which  has  come  under 
our  observation,  that  although  for  a  few  moments,  or  perhaps  for 
several  hours,  after  the  straight  position  has  been  assumed  in  these 
fractures,  the  upper  fragment  will  rise  spasmodically,  after  a  time, 
longer  or  shorter,  and  especially  after  the  application  of  the  side 
splints  and  bandages,  this  tendency  will  cease  altogether. 

My  convictions  upon  this  subject  are  clear,  but  since  they  do  not 
correspond  with  the  convictions  of  a  pretty  large  proportion  of  prac- 
tical surgeons,  I  am  compelled  to  regard  the  question  of  posture  in 
this  particular  fracture  as  still  open.  I  will  take  the  liberty  to  suggest, 
however,  that  it  is  by  the  results  of  carefully  recorded  experience  alone 
that  it  can  ever  be  determined,  and  not  by  any  reference  to  physiologi- 
cal or  anatomical  arguments,  which  I  suspect  have  had  hitherto  much 
more  influence  with  surgeons  in  respect  to  this  question  than  personal 
observation. 

In  hospitals,  and  in  private  practice  whenever  the  circumstances  of 
the  patient  will  warrant  the  expense,  a  bed  constructed  with  especial 
view  to  fractures  of  the  thigh  ought  to  be  regarded  as  an  essential 
part  of  the  apparatus ;  always  contributing  to  the  comfort  of  the 
patient,  if  it  is  not  absolutely  necessary  to  the  attainment  of  the  most 
complete  success.  Indeed,  where  some  form  of  fracture-bed  cannot  be 
procured,  and  the  patient  is  compelled  to  lie  upon  a  common  cot  bed 
instead,  or  a  common  post  bedstead,  or  upon  the  floor,  I  cannot  think 
the  surgeon  ought  to  be  held  in  any  degree  responsible  for  the  result. 

Fig.  169. 


Jenks's  fracture-bed.    From  Gibson. 


FRACTURES  OF  THE  SHAFT  OF  THE  FEMUR.      429 

The  fracture -beds  in  use  among  American  surgeons  are  exceedingly 
various,  among  which  I  will  mention,  as  being  especially  ingenious, 
the  beds  invented  by  Jenks,  Daniels,  the  Burges,  Addinell  Hewson,  of 
Philadelphia,^  J.  Ehea  Barton,  and  B.  H.  Coates,  of  the  same  city.^ 

Of  these  several  contrivances,  Jenks's  bed  (Fig.  169)  has  been  for  the 
longest  period  in  use  among  American  surgeons,  and  its  excellencies 
most  thoroughly  tested.  It  is  composed  of  "  two  upright  posts  about  six 
feet  high,  supported  each  by  a  pedestal;  of  two  horizontal  bars  at  the 
top,  somewhat  longer  than  a  common  bedstead;  of  a  windlass  of  the 
same  length  placed  six  inches  below  the  upper  bar ;  of  a  cog-wheel 
and  handle;  of  linen  belts,  from  six  to  twelve  inches  wide;  of  straps 
secured  at  one  end  to  the  windlass,  and  at  the  other  having  hooks 
attached  to  corresponding  eyes  in  the  linen  belts ;  of  a  head-piece 
made  of  netting ;  of  a  piece  of  sheet-iron  twelve  inches  long,  and  hol- 
lowed out  to  fit  and  surround  the  thigh ;  of  a  bed-pan,  box  and  cushion 
to  support  it,  and  of  some  other  minor  parts. 

"The  patient  lying  on  his  mattress,  and  his  limb  surrounded  by  the 
apparatus  of  Desault,  Hagedorn,  or  any  other  that  may  be  preferred, 
the  surgeon,  or  any  common  attendant,  will  only  find  it  requisite  to 
pass  the  linen  belts  beneath  his  body  [attaching  them  to  the  hooks  on 
the  ends  of  the  straps,  and  adjusting  the  whole  at  the  proper  distance 
and  length,  so  as  to  balance  the  body  exactly],  and  raise  it  from  the 
mattress  by  turning  the  handle  of  the  windlass.  While  the  patient  is 
thus  suspended,  the  bed  can  be  made  up,  and  the  feces  and  urine  evacu- 
ated. To  lower  the  patient  again,  and  replace  him  on  the  mattress, 
the  windlass  must  be  reversed.  The  linen  belts  may  then  be  removed, 
and  the  body  brought  in  contact  with  the  sheet."^ 

But  in  my  own  experience  no  bed  has  proved  so  complete  and  uni- 
versally applicable  as  the  fracture-bed  invented  more  recently  by 
Daniels  (E'igs.  170,  171,  172);  and  which  may  be  used  either  as  a  double 
inclined  plane,  or  as  a  single  horizontal  plane  suitable  for  the  sup- 
port of  the  patient  when  his  limb  is  dressed  with  the  straight  splint. 

Sometimes  I  have  had  constructed  a  simple  frame,  covered  with  a 
stout  canvas  sacking,  having  a  hole  at  a  point  corresponding  with  the 
position  of  the  nates,  and  this  I  have  laid  directly  upon  a  common  four- 
post  bedstead.  A  mattress  and  one  or  two  quilts  must  be  placed  upon 
the  boards  of  the  bedstead  underneath  the  sacking,  and  a  sheet  or  two 
above  the  sacking,  upon  which  last  the  patient  is  to  be  laid.  In  ar- 
ranging the  linen  underneath  the  patient  the  most  convenient  plan  is, 
instead  of  using  only  one  sheet,  which  will  require  that  a  hole  shall 
be  made  in  it  corresponding  to  the  hole  in  the  sacking,  to  employ  two 
sheets,  and,  doubling  them  separately,  to  bring  the  folded  margin  of 
each  from  above  and  from  below  to  the  centre  of  the  opening.  When 
the  patient  has  occasion  to  use  the  bed-pan  it  is  only  necessary  that 
two  or  four  persons  should  lift  this  frame,  and  place  under  each  corner 
a  block  about  one  foot  in  height,  or  it  may  be  raised  by  a  pulley  and 
ropes  suspended  from  the  ceiling. 

1  Hewson,  Amer.  Journ.  Med.  Sci.,  July,  1858,  p.  101. 

2  Eclectic  Repertory,  5tli  and  9th  vols. 
^  Gibson's  Surgery,  vol.  i.  p.  320. 


430 


FEACTURES    OF    THE    FEMUR. 


Fig.  170. 


Fig.  171. 


Fig.  172. 


E.  Daniel's  Fracture-Bed. 


FEACTURES    OF    THE    SHAFT    OF    THE    FEMUR.  431 

"A  represents  a  platform  of  a  suitable  length  and  width,  and  supported  by  four  legs,  a.  To  the  upper 
surface  of  the  platform  A  there  is  attached  a  cross-piece,  b,  at  a  short  distance  from  the  centre,  and 
directly  through  the  centre  of  the  platform  there  is  made  a  circular  hole  or  aperture,  c  (in  dotted  lines), 
said  hole  or  aperture  having  a  semicircular  cut  or  recess  in  the  cross-piece  5.  To  the  straight  edge  of  the 
cross-piece  b  there  is  attached,  by  hinges,  d,  a  board,  B,  termed  the  body  plane,  the  width  of  which  may 
correspond  with  that  of  the  platform  A,  and  when  depressed  its  outer  edge  may  be  even  with  the  edge  of 
the  platform.  The  sides  of  the  body  plane  may  be  elevated,  or  raised  so  as  to  be  slightly  concave  on  its 
outer  surface.  To  the  opposite  side  or  edge  of  the  cross-piece  6,  and  at  each  side  of  the  semicircular  cut 
or  recess  formed  by  the  hole  or  aperture  c,  there  are  attached  by  hinges,  e,  cast-iron  plates,  C  C,  which 
are  provided  with  grooves  or  ways  at  their  sides,  in  or  between  which  plates,  J)  D,  work.  The  plates 
C  0,D  D  (one  on  each  side)  are  thigh  planes,  and  their  edges  are  provided  with  ease  or  projections,/, 
in  which  a  shaft,  g,  worlcs,  one  on  each  plate  C.  On  each  shaft  g  there  is  placed  a  pinion,  which  gears 
into  a  rack  attached  to  the  under  surface  of  the  plates  i)i>.  At  one  end  of  the  shafts  g  there  are  attached 
ratchets,  g',  in  which  pawls,  y,  catch,  said  pawls  being  attached  to  the  sides  of  the  plates  C  C.  To  the 
outer  edges  of  the  plates  D  D  there  are  attached  by  hinges,  Tc,  boards,  E  E;  these  boards  are  leg  planes, 
and  are  slightly  raised  at  their  inner  ends,  where  they  are  connected  to  the  plates  D,  in  order  to  form 
depressions  to  correspond  to  the  shape  of  the  legs.  To  the  under  surface  of  each  leg  plane  there  is 
attached  a  metal  guide,  ?,  in  which  a  rack,  m,  works ;  the  outer  ends  of  the  racks  have  bars,  n,  projecting 
from  them  at  right  angles.  To  each  leg  plane  there  is  attached  a  shaft,  o,  having  a  pinion,  p,  and  ratchet, 
g,  thereon,  and  pawls,  r,  which  catch  into  the  ratchets  q,  the  pawls  being  attached  to  the  outer  sides  of 
the  leg  planes.  The  pinions  gear  into  the  racks  m.  The  body  plane,  and  also  the  thigh  and  leg  planes, 
are  covered  by  a  suitable  mattress,  E,  with  a  hole  made  through  it  to  correspond  with  the  hole  or  aper- 
ture c  in  the  platform  A,  and  the  mattre.ss  is  slit  or  cut  to  cover  properly  the  thigh  and  leg  planes  without 
interfering  with  their  movements.  To  the  under  side  of  the  platform  A  there  is  attached  by  hinges  a 
flap,  F,  having  a  stuffed  pad  or  cushion,  t,  upon  it,  which,  when  the  flap  i^is  secured  upwards  against  the 
platform  A,  fits  in  the  hole  or  aperture  e  in  the  platform  and  mattress.  The  flap  is  secured  against  the 
platform  by  a  button,  u." 

"VVe  may  also  floor  over  a  common  bedstead,  having  previously,  in 
case  it  is  an  adult  whom  we  have  to  treat,  removed  the  foot-board,  so 
that  we  may  extend  the  floor  two  or  three  feet  beyond  the  usual  length 
of  the  bedstead.  In  the  centre  of  this  floor  we  may  make  an  opening, 
so  arranged  as  to  be  closed  by  a  board  slid  underneath,  or  by  a  door 
fastened  with  a  couple  of  leathern  hinges,  and  closed  by  a  spring  catch. 

A  very  comfortable  bed,  especially  for  children,  can  sometimes  be 
made  from  a  cot.  But  it  will  be  necessary,  always,  to  nail  a  piece  of 
board  firmly  across  the  top  and  bottom  of  the  bedstead  when  the  sack- 
ing is  at  its  utmost  tension,  in  order  to  prevent  the  side  rails  from 
falling  together.  The  top  board  must  be  nailed  on  vertically  like  an 
ordinary  head-board,  so  as  to  prevent  the  pillows  from  falling  off,  but 
the  bottom  piece  should  beat  least  one  foot  wide,  and  laid  horizontally 
to  support  and  steady  the  apparatus  as  it  extends  beyond  the  foot. 

Having  had  occasion,  lately,  to  assist  Dr.  Treat,  of  this  city,  in  the 
management  of  a  fracture  of  the  thigh,  in  the  case  of  a  little  girl  not 
quite  three  years  old,  I  was  struck  with  the  simplicity  and  complete- 
ness of  an  arrangement  which  he  had  made  to  prevent  the  bed  and  the 
dressings  from  becoming  soiled  with  the  urine.  It  was  only  to  leave 
directly  underneath  the  nates  a  complete  opening  through  to  the  floor 
for  the  escape  of  the  urine,  and  to  protect  the  margins  of  the  sacking 
and  sheets,  which  came  nearly  together  at  the  opening,  with  pieces  of 
oiled  cloth  folded  upon  themselves.  It  was  found  that  not  only  the  bed 
was  in  this  way  kept  dry,  but  the  dressings  also;  it  being  now  observed 
that  the  dressings  had  become  wet  heretofore  by  soaking  up  the  mois- 
ture from  the  bed  rather  than  by  the  direct  fall  of  the  urine  upon  them. 

Having  prepared  the  bed  for  the  reception  of  the  patient,  we  may 
proceed  as  follows  in  the  case  of  a  simple  fracture. 


432  FEACTUEES    OF    THE    FEMUE. 

Lay  the  perineal  band  in  its  place,  and  four  pieces  of  bandage  trans- 
versely where  the  broken  thigh  is  to  repose ;  over  the  four  transverse 
bands  lay  a  firm  splint,  long  enough  to  reach  from  the  tuberosity  of 
the  ischium  to  the  lower  margin  of  the  ham,  and  nearly  as  wide  as  the 
diameter  of  the  thigh.  This  may  be  made  of  a  board  covered  with 
cotton  cloth,  and  carefully  stufted,  so  as  to  fit  all  the  inequalities  of 
the  several  portions  of  the  limb.  It  can  be  fitted  with  sufficient  accu- 
racy by  comparing  and  trying  it  upon  the  sound  limb.  Of  all  the 
side  splints  this  is  the  most  important,  and  the  greatest  care  ought  to 
be  exercised  in  its  construction. 

The  patient,  having  been  previously  stripped  and  washed  with 
warm  water  and  soap,  is  laid  upon  the  bed  with  his  thigh  reposing 
upon  the  back  splint;  the  head  and  trunk  being  at  first  moderately 
raised  to  prevent  any  strain  upon  the  muscles  of  the  front  of  the  thigh. 
An  assistant  seizes  the  knee  firmly  with  both  hands  and  makes 
moderate  traction  so  as  to  steady  the  limb,  and  at  the  same  time  pre- 
vent the  fragments  from  penetrating  the  flesh ;  while  the  surgeon  lays 
his  long  strips  of  adhesive  plaster  upon  each  side  of  the  leg  in  the 
manner  which  has  already  been  described,  protecting  the  ankles  with 
small  pads  made  of  cotton  batting.  Elevating  the  foot  a  little  more, 
he  proceeds  to  apply  a  roller  from  the  toes  up  to  the  ham.  Every- 
thing is  now  ready  for  the  long  splint,  which,  in  case  only  one  is  used, 
is  laid  outside  the  broken  limb,  and  the  perineal  band  adjusted  and 
tied  temporarily  in  a  bow  knot :  one  long  junk  is  pressed  between 
the 'splint  and  the  limb,  reaching  from  the  hip  to  the  heel,  and  imme- 
diately the  surgeon  fastens  the  extending  bands  to  the  foot-piece  or 
to  the  extending  screw,  and  tightens  it  moderately  so  that  the  assistant 
may  release  his  hold  upon  the  knee. 

The  whole  limb  is  now  steadied  and  at  rest,  and  the  patient  seldom 
fails  to  declare  himself  relieved ;  after  which,  the  surgeon  may  pro- 
ceed more  at  leisure  to  complete  his  dressings. 

A  padded  splint  should  next  be  laid  upon  the  inside  of  the  thigh, 
extending  from  the  groin  to  immediately  below  the  knee,  but  it  must 
not  be  allowed  to  press  much  upon  the  knee,  as  it  would  be  likely  to 
become  painful,  and  perhaps,  vesicate  the  skin  over  the  projecting 
bones.  Another  splint  in  front,  extending  from  the  groin  to  within 
one  inch  of  the  knee,  completes  the  inclosure  of  the  limb;  and  the 
whole  are  to  be  retained  in  place  by  tying  the  four  transverse  bands, 
previously  laid  under  the  limb,  around  the  three  short  lateral  splints, 
and  the  long  outside  splint.  In  some  cases  I  prefer  to  secure  the  short 
lateral  splints  to  the  limb  independently  of  the  long  splint,  and  then 
it  is  necessary  to  lay  a  fourth  short  splint  upon  the  outside  of  the 
limb,  between  it  and  the  long  splint,  otherwise  the  transverse  bands 
will  cut  into  the  flesh. 

The  perineal  band  ought  now  to  be  made  permanently  fast,  and  the 
extension  carried  to  the  point  of  utmost  tolerance  on  the  part  of  the 
patient,  while  the  surgeon  proceeds  to  apply  a  roller  from  the  instep 
to  the  groin,  enveloping  at  the  same  time  the  splint  and  the  limb  in 
its  successive  turns ;  but  as  he  progresses  upwards,  he  should  lay  be- 
tween the  limb  and  the  splint  and  underneath  the  limb  as  many  soft, 


FRACTURES    OF    THE    SHAFT    OF    THE    FEMUR.  433 

cotton  pads  as  maybe  needed  to  fill  up  all  the  inequalities;  these 
pads  it  will  be  found  necessary  to  extend  from  the  malleolus  externus 
to  near  the  middle  of  the  leg,  and  to  lay  them  under  the  tendo-Achillis 
and  knee,  outside  of  the  knee,  above  the  trochanter  major,  &c. 

Before  the  surgeon  leaves  he  should  ascertain  whether  the  extension 
is  too  violent,  or  whether  it  is  quite  painful,  and  in  either  case  it  must 
be  a  little  slackened. 

If  the  patient  is  a  child,  or  an  intractable  adult,  the  double  splint 
ought  to  be  preferred,  and  the  unbroken  limb  be  secured  to  the 
opposite  long  splint  in  the  same  manner  as  the  broken,  only  that  no 
perineal  band  or  extending  straps  are  needed  for  the  sound  limb. 

The  rules  which  have  now  been  laid  down  in  relation  to  the  order 
and  manner  of  dressing,  are  the  results  of  my  own  personal  experi- 
ence as  to  what  method  is  generally  the  most  convenient  and  useful ; 
but  circumstances  must  occasionally  require  that  they  should  be 
somewhat  varied  or  modified;  and  when  other  forms  of  apparatus 
are  employed  than  those  for  which  I  have  already  indicated  my  pre- 
ference, the  rules  of  procedure  must  be  determined  by  the  peculiarities 
of  the  apparatus.  In  short,  much  must  always  be  left  to  the  discretion 
of  the  surgeon,  only  that  he  never  can  be  at  liberty  to  dress  a  broken 
thigh  in  a  hasty  or  slovenly  manner. 

During  the  first  two  or  three  weeks  the  limb  ought  to  be  seen  daily, 
and  at  each  visit  a  careful  examination  of  every  portion  of  the  ap- 
parel should  be  made,  so  far  as  this  can  be  done  without  opening  or 
removing  the  dressings ;  and  whenever  anything  is  disarranged,  or 
has  become  too  tight  or  too  loose,  so  far  as  may  be  necessary  to  correct 
these  faults,  the  bandages  should  be  removed  and  readjusted.  Gene- 
rally they  can  be  tightened  by  over-stitching  or  by  additional  band- 
ages. If  the  patient  complains  of  pain  at  any  point  where  a  splint 
presses,  his  complaints  should  receive  prompt  attention,  and  the  cause 
should  be  ascertained  and  removed  if  possible.  Especially  ought  the 
surgeon  to  look  to  the  condition  of  the  perineum  ;  and  generally  no 
harm  comes  of  slackening  or  removing  the  band  whenever  this  part 
is  to  be  inspected,  since  the  weight  of  the  body  alone  is  sufficient, 
during  the  few  minutes  it  is  removed,  to  prevent  any  shortening  of 
the  limb. 

During  the  first  week  the  extension  should  be  increased,  according 
to  the  ability  of  the  patient  to  endure  it,  each  day ;  and  after  that, 
steadily  maintained  until  union  has  taken  place. 

In  the  case  of  an  adult,  we  ought  never  to  encourage  a  hope  that  he 
can  be  released  from  his  splints  in  less  than  eight  weeks,  although 
we  may  find  it  safe  to  remove  them  as  early  as  the  end  of  the  sixth 
week  ;  but  the  patient  seldom  wears  the  splints  too  long,  while  they  are 
often  removed  too  soon.  Remember  that  the  fragments  are  in  nine 
cases  out  of  ten  uniting  side  by  side  and  not  end  to  end ;  the  muscles 
which  act  upon  them  are  powerful,  and  the  weight  of  the  limb  is 
great,  so  that  the  time  within  which  the  limb  can  be  safely  trusted 
alone  is  never  short. 

The  extension  may,  however,  be  relaxed  as  soon,  generally,  as  the 
twenty-eighth  day,  and  the  leg  may  be  lifted  daily  after  this,  and  the 
28 


434 


FEACTUEES    OP    THE    FEMUE. 


knee  and  ankle  very  gently  flexed  and  rubbed,  but  never  so  early  as 
this  period  can  the  short  side  splints  be  abandoned  safely.  Still  more 
important  do  I  regard  the  continuance  of  the  long  side  splint — no 
lono-er  now  as  a  means  of  extension,  but  only  of  retention — lest  the 
weio^ht  of  the  limb  should  turn  the  foot  gradually  out,  or  occasion 
some  other  deformity. 

It  is  true  that  in  some  cases,  where  patients  are  remarkably  careful 
and  everything  has  gone  along  well,  I  have,  at  the  end  of  four  weeks, 
applied  a  paste  bandage  from  the  toes  to  the  groin,  and  permitted  them 
to  get  up  upon  crutches ;  but  I  would  not  dare  to  recommend  this 
practice  to  the  inexperienced  surgeon  or  to  the  incautious  patient.  It 
has  often  done  well,  but  sometimes  it  has  proved  disastrous.  It  is  an 
extra  hazard  which  the  surgeon  should  be  reluctant  to  incur. 

When  at  length  the  patient  is  permitted  to  leave  his  bed,  a  pair  of 
crutches  becomes  indispensable,  and  during  the  following  two  months 
but  little  weight  should  be  borne  upon  the  limb ;  and  in  rising  from 
the  bed  care  must  be  taken  lest  the  limb  should  be  so  situated  as  that 
its  weight  would  make  it  bend. 


§  5.  Fractures  of  the  Condyles. 

(a.)  Fractures  of  the  External  Condyle. 

Dr.  Alph.  B.  Crosby,  of  New  Hampshire,  has  published  an  account 
of  a  case  of  simple  fracture  of  the  external  condyle,  in  a  young  man 
twenty-one  years  of  age,  and  which  happened  from  a  sudden  twist  of 
the  limb,  while  he  was  undressing  himself  to  bathe.  He  was  "standing 
on  a  shelving  bank,  with  the  right  leg  flexed  over  the  left  in  order  to 
remove  his  pantaloons:  he  lost  his  balance,  partially  twisted  the  leg,  and 
fell  to  the  ground."  Six  months  after,  the  fragment  was  removed  by 
Dr.  Crosby,  through  an  incision  below  the  con- 
Fig.  173.  dyle.  The  recovery  of  the  young  man  has  been 
complete. 

The  accompanying  drawing  represents  the 
specimen  as  seen  from  its  lower  or  cartilaginous 
surface,  and  of  its  actual  size. 

Dr.  T.  S.  Kirkbride  has  also  reported  an  ex- 
ample of  simple  fracture  of  this  condyle,  which 
was  produced  by  the  kick  of  a  horse,  the  blow 
having  been  received  upon  the  inside  of  the  knee. 
When  this  patient  entered  the  Pennsylvania 
Hospital,  Dec,  1834,  the  knee  was  much  swollen 
and  crepitus  was  plainly  felt,  but  the  fragment 
was  not  much  displaced;  the  muscles  upon  the 
outer  side,  however,  were  so  strongly  contracted 
as  to  abduct  the  leg  and  produce  considerable 
angular  deformity.  The  limb  could  be  easily 
made  straight,  but  it  returned  to  its  former  position  of  abduction,  as 

'  Crosby,  New  Hampshire  Journ.  of  Med.,  1857. 


Dr.  Crosby's  specimen  of 
fracture  of  the  external  con- 
dyle. 


FRACTURES    OF    THE    CONDYLES. 


435 


Fig.  174. 


soon  as  it  was  released.  When  fully  extended,  slight  bending  of  the 
joint  did  not  give  severe  pain,  but  when  in  any  degree  flexed  all 
motion  was  very  painful. 

The  limb  was  placed  in  a  long  straight  frac- 
ture box,  and  cold  applications  were  made : 
great  swelling  followed.  It  was  kept  extended 
in  this  manner,  or  in  the  long  splint  of  De- 
sault,  twenty-eight  days ;  at  which  time  union 
seemed  to  have  taken  place,  but  the  motions  at 
the  joint  were  very  limited  and  productive  of 
great  pain.  From  this  period  the  limb  was 
laid  in  a  splint  so  constructed  as  that  the  angle 
at  the  knee  could  be  changed  daily.  At  the 
end  of  about  six  weeks  he  began  to  walk  on 
crutches,  and  he  could  then  flex  the  leg  to  a 
right  angle.^ 

Sir  Astley  has  related  a  case  of  compound 
fracture  of  the  same  condyle,  produced  by  fall- 
ing from  a  curb-stone  upon  the  knee.  The 
man  died  on  the  24th  day.  On  examination 
after  death  the  external  condyle  was  found  to  be 
broken  off,  and  also  a  considerable  fragment   ,  ^'^  ^'"^^  cooper's  case  of 

T    ,       T       T    r>  ,1  ^      r-    ^  ■    ^  o  fracture    of   the    external    con- 

was  detached  irom  the  shart  higiier  up.^  dyie. 


(b.)  Fractures  of  the  Internal  Condyle. 

Dr.  Thomas  Wells,  of  Columbia,  S.  C,  has  reported  an  example  of 
fracture  of  the  internal  condyle,  accompanied  with  a  dislocation  of  the 
head  of  the  tibia  outwards  and  backwards.  The  man  was  about  forty 
years  old,  and  intemperate.  Dr.  Wells  was  not  called  until  two  days 
after  the  injury  was  received,  when  he  found  the  limb  greatly  swol- 
len and  gangrenous.  The  man's  account  of  himself  was  that  while 
walking  in  the  back  yard  he  fell,  and  thus  dislocated  his  knee,  and  that 
he  was  then  brought  into  the  house,  being  unable  to  stand  upon  his 
feet.  It  does  not  appear  that  any  attempt  was  made  to  reduce  the 
limb,  probably  because  his  general  condition  indicated  that  speedy 
death  was  inevitable.  On  the  fourth  day  he  died.  The  autopsy  dis- 
closed, in  addition  to  the  dislocation  of  the  tibia,  that  a  thick  scale  of 
bone  was  broken  from  the  inner  part  of  the  inner  condyle,  but  it 
remained  attached  to  the  ligaments,^ 

Treatment  of  Fractures  of  either  Condyle. — The  few  cases  of  these  acci- 
dents which  have  been  reported  have  been,  with  one  or  two  exceptions, 
treated  in  the  straight  position.  In  Kirkbride's  case  any  degree  of 
flexion  was  painful,  although  there  was  little  or  no  displacement  of  the 
fragment;  and  we  think  we  can  see,  in  the  relative  position  of  the  arti- 
cular surfaces  of  the  tibia  and  femur,  a  sufficient  reason  why  the  straight 
or  nearly  straight  position  must  generally  be  preferred.      Whichever 

'  Kirkbride,  Amer.  Journ.  Med.  Sci.,  May,  1835,  vol.  xvi  p.  32. 

^  Sir  Astley  Cooper,  On  Disloc,  &c.,  op.  cit.,  p.  239. 

^  Wells,  Amer.  Journ.  Med.  Sci.,  May,  1832,  vol.  x.  p.  25. 


436  FRACTUEES    OF    THE    FEMUR. 

condyle  is  broken,  the  remaining  condyle  will  be  sufficient  to  prevent 
a  -dislocation  and  consequent  shortening  of  the  limb,  unless,  indeed, 
the  dislocation  has  already  occurred  as  an  immediate  consequence  of 
the  injury.  It  is  very  certain  that  it  would  not  take  place  from  the 
action  of  the  muscles  when  the  limb  was  straight.  In  the  flexed  posi- 
tion, I  can  conceive  that  it  might  take  place,  but  yet  not  easily.  It  is 
not  a  dislocation  of  the  limb,  then,  that  we  seek  chiefly  to  avoid,  but 
a  deflection  of  the  leg  to  the  right  or  to  the  left,  according  as  one  or 
the  other  of  the  condyles  has  been  broken.  It  will  be  readily  seen 
that,  in  order  to  resist  this  tendency,  nothing  but  the  straight  position 
will  answer,  and  that  for  this  purpose  it  will  be  necessary  to  lay  a 
long  splint  upon  one  or  both  sides  of  the  limb,  and  to  secure  the 
whole  length  of  both  thigh  and  leg  to  this  splint.  The  long  fracture- 
box  used  by  Kirkbride,  if  well  cushioned  on  all  sides,  seems  to  me  at 
once  to  answer  most  completely  this  important  indication,  rendering 
it  even  unnecessary  to  employ  a  bandage,  since  the  opposite  sides  of 
the  box  will  compel  the  limb  to  adopt  the  proper  position. 

I  need  scarcely  say  that  neither  extension  nor  counter-extension  will 
be  demanded. 

As  to  the  remainder  of  the  treatment,  it  must  consist  essentially  in 
the  active  employment  of  such  means  as  are  calculated  to  prevent  and 
allay  inflammation;  especially  ought  the-surgeon  not  to  omit  to  avail 
himself  of  so  valuable  an  antiphlogistic  agent  as  cool  water  lotions. 

As  soon  as  the  union  is  consummated  the  joint  surfaces  should  be 
submitted  to  passive  motion  in  order  to  prevent  anchylosis ;  and  it 
would  be  better  to  commence  this  so  early  as  to  hazard  somewhat  a 
displacement  of  the  fragment  than  to  wait  too  long.  It  may  not,  in 
some  cases,  be  improper  as  early  as  the  fourteenth  day,  and  in  nearly 
all  cases  it  should  be  practised  as  early  as  the  twenty-eighth. 

(c.)  Fractures  between  the  Condyles  and  across  the  Base. 

Etiology. — A  fracture  of  this  character  may  be  produced  by  a  blow 
received  upon  the  side  of  the  limb  or  upon  the  lower  extremity  of  the 
femur  ;  sometimes  the  blow  has  been  received  directly  upon  the  patella 
when  the  knee  was  bent,  and  Bichat  mentions  a  case  in  which  it  was 
produced  by  a  fall  upon  the  feet. 

Symptoms. — This  fracture  is  easily  distinguished  from  the  preceding 
by  the  much  greater  mobility  of  the  fragments  and  by  the  palpable 
shortening  of  the  limb,  since  an  overlapping  of  the  broken  ends  is 
here  almost  inevitable.  Each  fragment  may  be  felt  to  move  separately, 
and  the  motion  will  be  accompanied  with  crepitus. 

Prognosis. — The  danger  of  violent  inflammation  in  the  joint  is  im- 
minent, and  anchylosis  of  the  knee  is  to  be  anticipated  as  the  most 
favorable  result,  since  the  joint  surfaces  are  likely  to  be  rendered  im- 
movable by  fibrinous  deposits  in  their  immediate  vicinity,  and  also 
by  the  adhesion  of  the  muscles  to  one  another  and  to  the  bone  higher 
up,  where  the  fracture  of  the  shaft  has  occurred.  More  fortunate 
results  than  these  may,  indeed,  be  hoped  for,  inasmuch  as  they  have 
occasionally  been  noticed,  but  they  cannot  fairly  be  expected. 


I 


FEACTURES    OF    THE    CONDYLES.  437 

In  a  majority  of  cases,  snch  accidents  have  demanded,  either  imme- 
diately or  at  a  later  period,  amputation.  If  recovery  takes  place,  a 
shortening  of  the  thigh  is  inevitable. 

Treatment. — Malgaigne  saw  a  patient  who  had  been  treated  by 
Guerbo''s  with  the  aid  of  extension  and  counter-extension,  who  was 
confined  to  his  bed  five  months,  and  who  had  at  the  end  of  eight  years 
very  little  motion  in  the  joint,  and  he  seems  disposed  to  charge  in 
some  measure  these  unfortunate  consequences  to  the  position  in  which 
the  limb  was  placed,  namely,  the  straight  position.  But  in  my  opinion, 
it  is  much  more  reasonable  to  suppose,  that  if  the  treatment  was  at 
all  responsible  for  the  results,  the  error  consisted  in  too  long  and  un- 
necessary confinement,  and  in  too  much  extension.  I  suspect  that 
the  mere  matter  of  position  had  nothing  to  do  with  the  anchylosis. 
Malgaigne  does  not,  however,  himself  recommend  anything  more  than 
a  very  slight  amount  of  flexion  at  the  knee;  and  to  this  practice  I 
am  prepared  to  give  my  assent ;  since  it  will  give  to  the  limb  the  best 
position  in  case  anchylosis  does  occur,  and  it  is  not  inconsistent  with 
the  employment  of  the  moderate  amount  of  extension  which  alone  is 
justifiable  after  this  accident.  If  the  young  surgeon  should  differ 
with  me  in  opinion  as  to  the  necessity  or  propriety  of  using  great 
force  to  retain  the  fragments  in  place  and  prevent  overlapping,  I  beg 
him  to  consider  that  this  accident  never  happens  except  from  the 
application  of  an  extraordinary  force,  and  that  consequently  intense 
inflammation  and  swelling  are  almost  certain  to  ensue ;  and  that  in 
some  cases,  the  very  fact  that  immediately  after  the  accident,  or  for 
some  hours  succeeding,  no  swelling  occurs,  or  muscular  contraction, 
and  that  replacement  of  the  fragments  is  easily  accomplished,  is  evi- 
dence only  of  the  great  severity  of  the  injury,  and  that  the  whole 
system  is  lying  under  the  shock :  to  which,  if  the  patient  does  not 
succumb,  sooner  or  later  reaction  will  ensue,  and  the  fragments  will 
be  gradually  drawn  up  with  a  resistless  power.  The  surgeon  ought 
to  remember  also  that  to  make  extension  in  this  case,  he  is  obliged 
to  pull  upon  those  very  ligaments  and  tendons  about  the  joint  which, 
having  been  torn  or  bruised,  must  soon  become  exquisitely  sensitive. 

The  long  straight  box,  already  recommended  when  speaking  of 
fracture  of  one  condyle,  is  equally  applicable  here;  only  that  it  needs 
a  foot-board,  or  some  sort  of  foot-piece  to  which  an  extending  appa- 
ratus may  be  secured,  and  that  a  pillow  should  be  placed  under  the 
knee  to  give  the  limb  the  proper  flexion. 

Case. — A  man  was  admitted  into  St.  Thomas's  Hospital,  London, 
Sept.  17,  1816,  with  a  fracture  between  the  condyles,  accompanied  also 
with  a  fracture  through  the  shaft  higher  up,  occasioned  by  being  caught 
in  the  wheels  of  a  carriage  while  in  motion.  There  was  a  small 
wound  opposite  the  point  of  fracture,  and  the  external  condyle  was 
displaced  outwards. 

The  limb  was  laid  in  a  fracture  box,  and  in  a  position  of  semi- 
flexion. 

On  the  18th  of  Nov.,  the  external  condyle,  having  protruded  through 
the  skin,  and  being  dead,  was  removed  with  the  forceps,  bringing  with 
it  a  portion  of  the  articular  surface. 


438        •      FEACTUEES  OP  THE  PATELLA. 

On  the  Gth  of  Dec.  he  was  discharged  from  the  hospital,  and  in 
February  following  he  was  walking  without  any  support,  and  with 
the  free  use  of  the  joint.^ 

Case. — While  I  am  writing,  a  gentleman  living  about  eighty  miles 
from  town  has  been  thrown  from  his  carriage,  breaking  the  left  femur 
just  above  the  condyles  into  many  fragments,  so  that  when  I  saw  him, 
on  the  following  day,  the  attending  physician  showed  me  about  four 
or  five  inches  of  the  entire  thickness  of  the  shaft  which  he  had  re- 
moved. The  external  condyle  was  completely  separated  from  the 
internal,  and  was  quite  movable. 

In  this  case  the  attempt  to  save  the  limb  resulted  in  the  loss  of  the 
patient's  life  on  the  sixth  or  seventh  day. 


CHAPTER   XXIX. 

FEACTURES  OF  THE  PATELLA. 

Causes. — Of  fourteen  fractures  of  the  patella  which  have  come  under 
my  observation,  thirteen  were  the  result  of  direct  blows,  or  of  falls 
upon  the  knee.  In  the  remaining  example  the  fracture  was  due  solely 
to  muscular  action :  A  sailor,  aged  about  thirty  years,  had  caught  the 
heel  of  his  boot  in  a  knot-hole  in  the  floor,  which  threw  him  back- 
wards, and  in  the  effort  to  sustain  himself  the  patella  was  broken 
transversely.  Dr.  Kirkbride  has  reported  a  case  in  which  both  patellae 
were  broken  in  a  similar  manner  but  at  different  periods.  The  patient 
was  a  girl,  set.  29,  who  was  admitted  into  the  Pennsylvania  Hospital, 
Oct,  16,  1833.  "In  falling  backwards,  and  making  an  effort  to  save 
herself,"  the  right  patella  had  been  fractured.  She  was  dismissed 
cured  on  the  second  of  Dec,  and  on  the  20th  of  April  following  she 
was  readmitted,  with  a  fracture  of  the  left  patella,  produced  in  the 
same  rnanner  as  before ;  but  in  her  effort  to  save  the  right  limb,  the 
left  received  all  the  strain  and  the  patella  gave  way,^  Dr,  Kirkbride 
records  another  instance  of  fracture  from  muscular  exertion  in  a  man 
set,  32,  who  attempted  to  jump  into  a  cart,  by  raising  his  body,  with 
his  hands  resting  upon  the  bottom  of  the  vehicle;^  and  Dr,  Hayward, 
of  Boston,  saw  a  case  in  the  Mass.  Gen.  Hospital,  in  a  man  set,  67, 
which  occurred  in  consequence  of  a  false  step  in  descending  a  flight 
of  stairs,^ 

Pathology. — All  the  fractures  produced  by  muscular  action  have 
been  found  to  be  transverse,  and  the  same  is  true  generally  of  fractures 

1  A.  Cooper  on  Disloc,  &c.,  op,  cit.,  p.  239, 

'^  Kirkbride,  Amer.  Journ,  Med.  Sci.,  Aug.  1835,  vol.  xvi.  p.  330. 

3  Hayward,  Am.  Journ,  Med,  Sci.,  vol,  xxx,,  from  New  Eng.  Quart,  Journ  ,  July,  1842. 


FRACTURES  OF  THE  PATELLA. 


439 


produced  by  direct  blows;  occasionally,  however,  we  meet  with  lon- 
gitudinal fractures,  or  with  fractures  more  or  less  oblique  and  com- 
minuted. Eleven  of  the  fractures  seen  by  me  were  simple  and  trans- 
verse;  one  was  simple  and  oblique,  and  one  was  comminuted.     The 

Fig.  176. 


oblique  fracture  was  in  the  person  of  a  child  five  years  old,  who  fell 
on  his  left  knee,  Jan.  31,  1848,  breaking  off  a  small  fragment  from 
the  upper  and  inner  margin  of  the  patella.  It  did  not  separate  from 
the  main  fragment  except  when  the  knee  was  flexed,  and  it  was  then 
thrown  directly  forwards,  presenting  to  the  finger  a  sharp  point.  Dr. 
Flint,  who  was  with  myself  in  attendance,  kept  the  leg  extended  and 
had  the  knee  constantly  moistened  with  cool  lotions.  Six  months 
after,  I  could  not  discover  any  traces  of  the  accident.  There  is  a 
specimen,  illustrating  a  similar  fracture,  but  not  united,  in  the  collection 
at  St.  Thomas's  Hospital,  London.^  Dupuytren,  A.  Cooper  and  others 
have  also  mentioned  cases  of  longitudinal  fracture. 

I  have  seen  a  double  transverse  fracture,  or  a  fracture  of  both 
patellae  in  a  man  set.  22,  who  fell  from  a  third  story  window,  striking, 
he  says,  upon  his  knees.  He  was  taken  to  the  Hospital  of  the  Sisters 
of  Charity,  in  this  city,  and,  after  a  few  weeks,  made  an  excellent 
recovery. 

Fig.  177. 


Sy'm2:)toms. — The  symptoms  which  characterize  a  transverse  fracture 
of  the  patella  are  sufficiently  diagnostic.  The  fragments  are  separated 
from  each  other,  the  superior  fragment  being  drawn  upwards  more  or 
less,  according  to  the  power  and  activity  of  the  muscles,  or  the  degree 
to  which  the  ligamentous  covering  of  the  patella  has  been  torn.     In 


'  A.  Cooper,  On  disloc,  &c.,  op.  cit.,  p.  232. 


440 


FRACTURES  OF  THE  PATELLA. 


Fig.  178. 


fragments  separated  by  flexion  of  the 
knee. 


some  cases,  also,  the  violent  flexion  of  the  knee,  Fig.  178,  has  completed 
the  separation  which  otherwise  might  have  been  only  partial.  By 
passing  the  finger  along  the  anterior  surface  of  the  limb  with  a  moderate 

degree  of  firmness,  the  depression  between 
the  fragments  will  be  made  manifest. 

No  crepitus  can  be  expected  unless  the 
fragments  remain  in  contact,  a  condition 
which  is  very  unusual.     The  patient  is 
unable  to  stand,  and  especially  is  the  power 
of  extending  the  leg  upon  the  thigh  com- 
pletely lost.   Usually  a  good  deal  of  swell- 
ing immediately  succeeds  the  accident,  and 
after  a  time  the  skin  becomes  more  or  less 
discolored  from  effusions  of  blood.   If  the 
fracture  is  longitudinal  or  oblique,  a  slight 
lateral  separation  is  usually  present,  but 
not  always  very  easily  detected. 
Prognosis. — One  of  my  patients,  who  had  a  comminuted  fracture, 
with  other  serious  injuries,  died,  but  not  as  a  consequence  of  the  frac- 
ture.   In  the  following  case  the  fragments  appear  never  to  have  united, 
although  the  patient  recovered. 

John  Sharkie,  aet.  24,  a  soldier  in  the  British  service,  while  serving 
in  the  East  Indies,  was  struck  on  the  right  knee  while  he  was  in  a 
sitting  posture,  with  his  leg  bent  under  him. 

He  was  immediately  placed  under  the  charge  of  the  surgeon  of  the 
89th  regiment  of  infantry.  During  the  first  eleven  days  no  splints  or 
bandages  were  applied,  on  account  of  the  severe  inflammation  and 
swelling.  A  compress  was  then  placed  over  both  fragments,  and  they 
were  bound  together  by  rollers,  &c.  The  whole  limb  was  suspended 
on  an  inclined  plane,  the  foot  being  made  fast  to  a  foot-board.     This 

treatment  was  continued  four  months. 
When  the  bandages  were  removed  the 
limb  was  badly  swollen ;  and  immediately 
the  upper  fragment  was  drawn  up  toward 
the  body.  Eighteen  months  elapsed  be- 
fore he  could  walk,  even  with  the  aid  of 
a  cane. 

March  27, 1855,  twenty-nine  years  after 
the  injury  was  received,  he  was  an  inmate 
of  the  Buffalo  Hospital,  and  I  was  per- 
mitted to  examine  his  knee  carefully. 

The  lower  fragment  is  not  displaced, 
but  when  the  leg  is  straight  upon  the 
thigh  the  upper  fragment  lies  two  and  a 
half  inches  from  the  lower,  and  when  it  is 
flexed  upon  the  thigh  the  upper  fragment 
is  removed  five  inches  from  the  lower. 
There  is  no  ligament  or  other  bond  of  union,  so  far  as  I  can  discover. 
He  walks  with  very  little  or  no  halt,  but  he  cannot  walk  fast. 

In  every  other  instance  which  has  come  under  my  notice  union  has 


Fig.  179. 


FRACTUEES    OF    THE    PATELLA.  441 

taken  place  at  periods  varying  from  twenty-four  to  fifty-eight  days, 
the  average  being  thirty-eight  days.  Eleven  cases  have  united  by  a 
ligament  varying  in  length  from  one-quarter  to  one-half  an  inch. 
These  measurements,  made  upon  the  living  subject,  may  not  be 
mathematically  accurate,  but  they  cannot  be  far  from  the  truth. 

In  one  instance,  the  case  of  a  man  set.  40,  the  fracture  having  been 
treated  by  another  surgeon,  the  ligamentous  union,  at  first  complete, 
seems  to  have  subsequently  given  way  in  part.  He  called  upon  me 
for  advice  nine  weeks  after  the  fracture  had  occurred.  The  patella 
was  surrounded  with  bony  callus,  so  that  it  was  considerably  wider 
than  the  other.  The  fragments  seemed  to  be  united  by  a  short  liga- 
ment, except  on  the  inner  side,  where  there  was  a  separation  or 
rupture  of  the  ligament  to  the  extent  of  one-quarter  of  an  inch.  The 
patient  explained  this  by  saying  that  the  splint  was  removed  at  the 
end  of  four  weeks,  and  that  after  a  week  more  he  began  to  walk,  but 
that  he  almost  immediately  felt  it  tear  or  give  way  on  the  inner  side. 

Dr.  Kirkbride  has  reported  a  case  of  ligamentous  union  of  the 
patella,  in  which  the  ligament  was  two  and  a  half  inches  long,  and 
was  attached  only  to  the  inner  margins  of  the  fracture.  "  He  was  able 
to  walk  as  rapidly  as  ever,  and  without  perceptible  limping."^  A  similar 
case  is  reported  by  Dr.  Watson,  of  New  York,  in  which  the  fragments 
became  separated  three  and  a  half  inches.^  In  both  instances  the  frag- 
ments were  supposed  to  have  united  b}^  a  short  ligament,  which  had 
become  lengthened  by  premature  use  of  the  limb;  in  the  case  reported 
by  Kirkbride,  the  ligament  seemed  to  have  partly  torn,  as  in  the  case 
reported  by  myself.  Dr.  Coale  presented  to  the  Boston  Society  for 
Medical  Improvement,  at  its  April  meeting  in  1856,  a  specimen  of  a 
fractured  patella  taken  from  a  man  sixty  five  years  old,  the  fracture 
having  occurred  ten  years  before.  The  fragments  were  at  first  so 
closely  united  that  no  division  between  them  could  be  discovered,  but 
subsequently  they  became  separated  at  their  outer  edges  one  inch, 
and  at  their  inner  edges  one-eighth  of  an  inch.^ 

Twice,  I  believe,  I  have  seen  a  bony  union  of  the  patella.  The  first 
instance  is  that  to  which  I  have  already  referred  as  an  oblique  or 
longitudinal  fracture  across  one  corner  of  the  patella;  and  in  the  other 
example  the  action  of  the  muscles  upon  the  upper  fragment  was  pre- 
vented by  the  occurrence  of  a  fracture  of  the  shaft  of  the  femur  at  the 
same  time,  which  permitted  the  thigh  to  shorten  upon  itself  The 
man  was  about  twenty-five  years  old,  and  in  a  fall  from  a  scaffold  had 
broken  his  left  femur,  and  also  the  patella.  The  patella  was  broken 
transversely,  near  its  middle,  and  also  longitudinally,  near  its  inner 
margin.  The  fragments  were  all  distinctly  made  out.  Drs.  Lewis  and 
Dayton,  of  this  city,  were  in  attendance,  and  on  the  fifth  day  I  was 
called  in  consultation.  We  dressed  the  limb  with  a  long  straight 
splint,  employing  moderate  extension  and  counter-extension.  The 
patella  was  covered  with  strips  of  adhesive  plaster.  On  the  fifty- 
eighth  day  I  found  the  fragments  of  the  patella  united. 

'  Kirkbride,  Amer.  Journ.  of  Med.  Sciences,  vol.  xvi.  p.  32. 

2  Watson,  N.  Y.  Journ.  of  Med.  and  Surgery,  vol.  iii.,  first  series,  p.  366. 

"  Coale,  Boston  Med.  and  Surg.  Journal,  vol.  liv.  p.  402. 


442  FRACTUEES  OF  THE  PATELLA. 

June  3,  1854,  five  months  after  the  accident,  I  examined  the  limb 
carefully.  The  femur  was  shortened  half  an  inch,  and,  although  the 
two  main  fragments  of  the  patella  were  separated  half  an  inch,  the 
bond  of  union  seemed  to  be  bone.  It  was  hard,  and  allowed  of  no 
motion  in  the  upper  fragment  separate  from  the  lower.  The  lateral 
fragment  was  also  apparently  united  by  bone  and  in  place.  He  had 
but  little  motion  in  the  knee-joint,  yet  he  walked  very  well,  and  was 
able  to  pursue  his  trade,  as  a  carpenter,  without  much  inconvenience. 

Sir  Astley  Cooper  succeeded  in  obtaining  a  bony  union  in  some 
longitudinal  fractures,  but  in  a  majority  of  cases  it  failed,  owing  to  the 
want  of  apposition  in  the  fragments.  It  might  seem  that  it  would  be 
easy  to  accomplish  apposition  in  all  longitudinal  fractures,  but  expe- 
rience has  shown  that  it  is  not  always,  the  fragments  being  kept 
asunder  partly  by  the  actiou  of  the  oblique  fibres  of  the  vasti  and 
partly  by  the  pressure  of  the  condyles  of  the  femur,  especially  when 
the  leg  is  slightly  flexed. 

Whether  the  fracture  is  transverse  or  longitudinal,  a  bony  union 
may  occasionally  be  obtained  when  the  fragments  are  retained  in 
absolute  contact  for  a  sufficient  length  of  time;  but  the  failure  to 
procure  a  bony  union  is  not  a  matter  of  consequence,  since  a  short 
ligament  is  equally  useful. 

Post,  of  New  York,  has  reported  three  cases  of  compound  fracture 
of  the  patella  extending  into  the  knee-joint,  brought  to  a  successful 
termination.^ 

In  a  case  mentioned  by  Dr.  Eve,  of  Augusta,  occasioned  by  the  kick 
of  a  horse,  and  in  which  amputation  became  necessary  on  the  tenth 
day,  "  the  knee-joint  was  found  filled  with  dark  grumous  blood ;  a 
portion  of  the  cartilage  of  the  internal  condyle  of  the  os  femoris  was 
chipped  off,  and  the  patella  broken  into  a  number  of  fragments."^ 

Dr.  Lewitt,  of  Michigan,  has  related  a  case  of  fracture  in  a  lad  set. 
16,  produced  by  striking  his.  knee  against  a  piece  of  timber,  which 
resulted  in  suppuration  of  the  knee-joint,  but  from  which  he  finally 
recovered  with  the  perfect  use  of  the  limb.  The  fracture  of  the  patella 
was  oblique,  traversing  only  its  upper  and  outer  margin,  and  it  was 
never  much  displaced.^ 

Treatment. — Dr.  Sanborn,  of  Lowell,  Mass.,  has  contrived  a  method 
of  treating  transverse  fractures  of  the  patella,  E'igs.  180,  181,  and  also 
cases  of  rupture  of  the  ligamentum  patellee,  which  I  shall  take  the 
liberty  of  describing  in  his  own  language. 

"  While  repairing  one  of  the  public  buildings  of  this  city,  two  men, 
masons  by  trade,  were  precipitated,  by  the  breaking  of  a  staging,  a 
distance  of  twenty-five  feet  on  to  a  plank  floor.  One  of  the  men 
received  a  fracture  of  the  base  of  the  skull,  and  died  in  consequence  ; 
the  other  escaped  with  a  rupture  of  the  ligamentum  patella3.  The 
man  Avas  conveyed  home,  and  a  neighboring  physician  applied  the 
usual  dressing  of  a  '  figure-of-eight'  bandage,  with  a  splint  behind  the 

'  Post,  New  York  Journ.  of  Med.,  vol.  ii.,  first  series,  p.  367. 

^  Eve,  Southern  Med.  and  Surg.  Journ.,  1848  ;  also  Bost.  Med.  Journ.,  vol.  xxxvii. 
p.  427. 

"  Lewitt,  Mediual  Independent,  Sept.  1856. 


FEACTUEES  OF  THE  PATELLA. 


443 


joint.  In  the  course  of  the  following  night,  the  pain  in  the  knee 
became  intolerable  from  the  swelling  and  consequent  tightness  of  the 
bandage,  and  all  dressings  were  removed.  The  following  day  the  case 
was  transferred  to  my  care  by  the  attending  physician.  I  found  the 
knee  a  good  deal  swollen  and  inflamed,  and  there  was  evidence  of 
extensive  extravasation  of  blood  into  the  joint  and  surrounding  tissue. 
The  patella  was  drawn  up  the  thigh  for  a  distance  of  four  inches ;  and, 
although  it  could  be  brought  down  nearly  to  its  proper  situation  by 
the  hand,  a  bandage  sufficiently  tight  to  keep  it  there  could  not  be 
bornev  The  object  to  be  accomplished,  then,  was  to  bring  a  sufficient 
force  to  bear  on  the  patella,  without  making  pressure  on  the  joint  or 
impeding  the  circulation  of  the  limb.  And  it  was  accomplished  in 
this  manner :  A  strip  of  ordinary  adhesive  plaster,  four  feet  long  and 
two  and  a  half  inches  wide,  was  applied  to  the  limb  from  the  upper 
portion  of  the  thigh  to  the  middle  of  the  leg,  leaving  at  the  knee  a 
free  loop.  A  roller  bandage  was  then  applied  above  and  below  the 
knee,  for  the  purpose  of  securing  the  plaster  and  controlling  the  cir- 
culation and  muscular  contraction.  A  small  stick,  six  or  eight  inches 
in  length,  then  being  put  through  the  loop  over  the  knee,  the  plaster 
was  twisted  until  the  patella  was  brought  nearly  down  to  its  proper 
situation.  Before  applying  the  tivist^  a  hard  compress  was  placed 
above  the  edge  of  the  patella  in  such  a  manner  as  to  bring  the  force 
to  bear  dire.ctly  upon  that  bone.  ^  *  *  *  Leeches  and  fomenta- 
tions were  applied  to  the  joint,  and,  as  the  inflammation  subsided,  the 
plaster  was  tightened,  until  (at  about  the  sixth  day)  the  bone  was 
brought  fully  down  to  its  normal  situation.  It  was  there  held,  with- 
out the  slightest  uneasiness  to  the  patient,  until  union  took  place.     In 


Fi?.  ISO. 


E.  K.  Sanljorn's  mode  of  dressing  a  fractured  patella, 
of  adhesive  plaster  lifted  into  a  loop  over  the  knee. 


Represents  the  limb  covered  with  a  hroad  band 


Fis.  181. 


Same  apparatus  ;  dressing  complete.  Represents  the  band  of  adhesive  plaster  secured  in  place  by  a 
roller,  -n-hile  the  loop  is  being  drawn  together  by  torsion.  Underneath  the  plaster,  and  just  above  the 
upper  fragment  of  the  patella,  a  compress  is  placed  to  aid  the  adjustment. 


444 


FEACTUEES  OF  THE  PATELLA. 


three  weeks  the  man  was  able  to  walk  alone,  with  the  plaster  still 
applied,  and  the  recovery  was  ultimately  perfect.  There  is  now  no 
perceptible  halt  in  the  gait. 

"  Within  the  last  two  years  several  cases  of  transverse  fracture  of 
the  patella  have  been  treated  by  this  method,  both  by  myself  and 
others  in  this  vicinity,  and  with  perfect  success."^        , 

The  dressing  which  I  have  usually  employed  in  the  treatment  of 
this  fracture,  consists  of  a  single  inclined  plane,  of  sufficient  length  to 
support  the  thigh  and  leg,  and  about  six  inches  wider  than  the  limb 
at  the  knee.  This  plane  rises  fi'om  a  horizontal  floor  of  the  same 
length  and  breadth,  and  is  supported  at  its  distal  end  by  an  upright 
piece  of  board,  which  serves  both  to  lift  the  plane  and  to  support  and 
steady  the  foot.  The  distal  end  of  the  inclined  plane  may  be  elevated 
from  six  to  eighteen  inches,  according  to  the  length  of  the  limb  and 
other  circumstances.  Upon  either  side,  about  four  inches  below  the 
knee,  is  cut  a  deep  notch.  The  foot- piece  stands  at  right  angles  with 
the  inclined  plane,  and  not  at  right  angles  with  the  horizontal  floor ; 
it  may  be  perforated  with  holes  for  the  passage  of  tapes  or  bandages 
to  secure  the  foot. 

Having  covered  the  apparatus  with  a  thick  and  soft  cushion  care- 
fully adapted  to  all  the  irregularities  of  the  thigh  and  leg,  especial  care 
being  taken  to  fill  completely  the  space  under  the  knee,  the  whole 
limb  is  now  laid  upon  it,  and  the  foot  secured  gently  to  the  foot-board, 
between  which  and  the  foot  another  cushion  is  placed. 

The  body  of  the  patient  should  also  be  flexed  upon  the  thigh,  so  as 
the  more  effectually  to  relax  the  quadriceps  femoris  muscle. 

Fig.  182. 


The  Author's  Mode  of  Dressing  a  Fractured  Patella. 
a.  Bed.  h.  Floor  of  apparatus,  c.  Foot-piece,  furnished  with  fenestrse  through  which  straps  may  be 
passed  to  secure  the  foot,  and  with  pins  on  each  margin,  d.  Single  inclined  plane  fastened  to  the  foot- 
piece  at  any  height,  by  means  of  a  hook  dropped  over  the  pins,  e,  e.  Cushion:  thicker  under  the  knee 
than  at  either  end.  /.  Roller  to  secure  leg  and  thigh  to  the  inclined  plane  ;  not  completely  applied,  g. 
Adhesive  plasters  laid  over  a  compress  and  crossed  under  the  splint.  Those  from  above  pass  through  a 
notch  in  the  splint  below  the  knee,    h,  h.  Ends  of  the  compresses,  seen  from  under  the  adhesive  plasters. 

A  compress  made  of  folded  cotton  cloth,  wide  enough  to  cover  the 
whole  breadth  of  the  knee,  and  long  enough  to  extend  from  a  point 


1  Boston  Med.  and  Surg.  Journ  ,  vol.  liv.  p.  174. 


FEACTUEES    OF    THE    PATELLA.  445 

four  inches  above  the  patella  to  the  tuberosity  of  the  tibia,  and  one- 
quarter  of  an  inch  thick,  is  now  placed  on  the  front  of,  and  above  the 
knee.  While  an  assistant  presses  down  the  upper  fragment  of  the 
patella,  the  surgeon  proceeds  to  secure  it  in  place  with  bands  of 
adhesive  plaster.  Each  band  should  be  two  or  two  and  a  half  inches 
wide,  and  sufficiently  long  to  inclose  the  limb  and  splint  obliquely. 
The  centre  of  the  first  band  is  laid  upon  the  compress  partly  above  and 
partly  upon  the  upper  fragment,  and  its  extremities  are  brought  down 
so  as  to  pass  through  the  two  notches  on  the  side  of  the  splint  and 
close  upon  each  other  underneath.  The  second  band,  imbricating  the 
first,  descends  a  little  lower  upon  the  patella  and  is  secured  below  in 
the  same  manner.  The  third,  and  so  on  successively  until  the  whole 
extent  of  the  compress  and  knee  is  covered,  is  carried  more  nearly  at 
right  angles  around  the  leg  and  splint ;  the  last  bands  passing 
obliquely  from  below  the  ligamentum  patellae  upwards  and  backwards. 
The  dressing  is  now  completed  by  passing  a  cotton  roller  around  the 
whole  length  of  the  limb  and  splint,  commencing  at  the  toes  and 
ending  at  the  groin.  This  is  to  be  applied  lightly,  as  its  object  is  only 
to  support  and  steady  the  limb  upon  the  splint. 

The  great  advantage  which  this  mode  of  dressing  possesses  is,  that  it 
does  not  ligate  the  leg  or  thigh  completely,  since,  on  either  side,  between 
the  broad  margins  of  the  splint  and  the  points  where  the  straps  and 
bandages  touch  the  limb,  there  is  a  space,  more  or  less  considerable, 
against  which  no  pressure  is  made,  and  through  which  the  circulation 
may  go  on  without  impediment;  so  that,  however  firmly  the  bands 
are  drawn  across  the  knee,  no  swelling  occurs  in  the  foot.  As  to  its 
efficiency,  the  best  testimony  which  can  be  presented  is  the  simple  fact 
that  of  six  cases  treated  by  this  method,  four  have  united  by  a  liga- 
ment of  only  one-quarter  of  an  inch  in  length,  and  two  by  a  ligament 
of  half  an  inch. 

The  following  example  of  a  fracture  of  both  patellee  will  illustrate 
the  general  advantages  of  this  dressing: — 

John  Dundas,  set.  22,  fell,  October  22,  1852,  in  the  night  while 
asleep,  from  a  window  in  the  third  story  of  a  dwelling-house,  striking 
with  his  knees  upon  the  stone  side- walk. 

On  the  tenth  day  I  took  charge  of  him  at  the  Buffalo  Hospital  of 
the  Sisters  of  Charity.  I  found  both  limbs  in  Gibson's  modification 
of  Hagedorn's  splint  for  fractured  thighs,  with  a  figure-of-8  band- 
age loosely  applied.  The  fragments  were  very  much  displaced,  I 
immediately  proceeded  to  inclose  each  leg,  from  the  toes  upwards 
as  far  as  the  knee,  with  a  paste  bandage,  and  then,  having  properly 
cushioned  the  limbs  and  laid  them  over  two  separate  inclined  planes,  I 
secured  the  fragments  in  place  with  adhesive  plaster ;  subsequently  the 
limbs  and  planes  were  made  fast  together  by  successive  turns  of  a  roller. 

The  knees  were  examined  frequently,  and  the  dressings  occasionally 
renewed. 

ISiOvember  28,  1852,  thirty-seven  days  after  the  fractures  had  oc- 
curred, the  splints  and  bandages  were  finally  removed.  Both  patellae 
had  united  by  ligamentous  tissue,  the  length  of  which  was  about  one- 
quarter  of  an  inch. 


446 


FEACTUEES  OF  THE  PATELLA. 


In  a  few  weeks  more  he  left  the  hospital,  walking  with  only  a  slight 
impairment  of  the  motions  of  the  joints. 

The  plan  adopted  by  M.  Gama,  of  Yal  de  Grace,'  is  similar  to  that 
which  I  have  now  described,  but  the  splint  upon  which  the  limb 
reposes  is  not  so  wide,  while  width  is  an  essential  point  in  the  attain- 
ment of  the  objects  which  I  propose.  Dr.  Neill,  of  Philadelphia,  uses 
also  the  adhesive  plaster  straps,  but  they  are  not  placed  outside  of  the 
splint.^  Such,  also,  I  understand  to  be  Mr.  Alcock's  method  of  using 
the  adhesive  plaster.^ 

The  dressing  and  apparatus  employed  by  Wood,  of  King's  College 
Hospital,  is  very  similar  to  my  own,  but,  as  will  be  seen  by  the  accom- 
panying drawing  (Fig.  183),  the  splint  is  only  five  or  six  inches  wide. 
Dr.  Wood  has  substituted  hooks  for  the  notches." 


Fig.  183. 


Wood's  apparatus. 


Dr.  Dorsey,  of  Philadelphia,  employed  a  very  simple  apparatus.  Fig. 
184,  which  will  serve  to  illustrate  the  general  plan  adopted  by  many 
surgeons,  both  at  home  and  abroad.    It  is  liable,  however,  to  the  objec- 

Fig.  184. 


Jolin  Syng  Dorsey's  patella  spliat. 

tion  already  stated — namely,  that  it  interrupts  too  much  the  circulation 
of  the  limb.  His  apparatus  consists  of  a  piece  of  wood  half  an  inch  thick 
and  two  or  three  inches  wide,  and  long  enough  to  extend  from  the 

'  Malgaigne,  Traite  des  Fractures,  etc.,  op.  cit.,  p.  764. 
2  Philadelphia  Med.  Examiner,  vol.  x.  p.  1. 

*  Practical  Observations  on  Fractures  of  the  Patella  and  of  the  Olecranon,  hy  Tho- 
mas Alcock,  p.  296. 

^  Fergusson's  Surgery,  p.  307. 


FRACTUEES    OF    THE    PATELLA.  447 

buttock  to  the  heel;  near  the  middle  of  this  splint,  and  six  inches 
apart,  two  bands  of  strong  doubled  muslin,  a  yard  long,  are  nailed. 
The  splint  is  then  cushioned,  and  the  limb  being  laid  upon  it,  a  roller 
being  first  applied  from  the  ankle  to  the  groin,  encompassing  the  knee 
in  the  form  of  the  figure-of-8;  after  which  the  two  muslin  bands  are 
secured  across  the  knee  in  such  a  manner  as  that  the  lower  one  shall 
draw  down  the  upper  fragment,  and  the  upper  one  elevate  the  lower 
fragment. 

A  sibgle  instance  will  explain  the  danger  of  ligation  to  which  I  have 
alluded,  and  which,  although  it  may  be  greater  in  case  a  starch  or  dex- 
trine bandage  is  used,  exists  in  some  degree,  whatever  material  for 
bandaging  is  employed,  if  it  is  applied  to  the  whole  circumference  of 
the  limb,  and  constant  attention  is  not  paid  to  the  progress  of  the 
swelling. 

"A  vine-dresser,  set.  40,  of  a  good  constitution,  fell  and  received  a 
simple  transverse  fracture  of  the  patella  on  the  15th  of  January.  The 
medical  officer  called  upon  to  attend  him  applied  first  a  bandage  for  the 
purpose  of  drawing  together  the  fragments,  and  afterwards  a  starched 
bandage  extending  from  the  toes  to  the  upper  part  of  the  thigh ;  the 
limb  was  then  put  upon  an  inclined  plane.  The  patient  was  visited  a 
few  times,  but,  as  he  scarcely  suffered,  the  apparatus  was  in  no  way 
disturbed.  On  the  first  of  March  (sixteenth  day)  the  attendant  re- 
turned to  remove  the  bandage,  when  the  odor  arising  from  the  limb 
led  him  to  believe  that  gangrene  had  taken  place,  and  Dr.  Defer  was 
sent  for.  Dr.  Defer  found  the  limb  in  the  following  state:  The  toes 
which  were  not  covered,  by  the  bandage  were  completely  insensible 
and  mummified.  The  bandage  being  removed,  the  gangrene  was  per- 
ceived to  extend  within  seven  inches  of  the  knee,  and  was  arrested  in 
its  progress.  The  foot  was  cold,  and  was  totally  insensible ;  the  epi- 
dermis was  raised  up,  and  was  beginning  to  be  separated  from  the  skin. 
The  articulation  of  the  ankle  was  exposed,  and  the  ligaments  destroyed. 
The  bones  of  the  leg  were  also  exposed  in  their  lower  third,  and  the 
tendons  were  in  a  sloughy  state.  Amputation  was  performed,  and  the 
patient  recovered.'" 

Very  little  better  than  the  starch  bandage,  and  exposing  the  patient 
in  a  still  greater  degree  to  the  dangers  of  ligation  and  strangulation, 
are  either  of  the  methods  recommended  by  Sir  Astley  Cooper,  Figs. 
185,  186. 

Fig.  185. 


Sir  A.  Cooper's  method  by  circular  tapes. 
Amer.  .Journ.  Med.  Sci.,  voL  xxiv.  p.  462,  from  Gazette  Medicale,  No.  28. 


448 


FEACTURES  OF  THE  PATELLA. 

Fig.  186. 


Sir  A.  Cooper's  method  by  a  leather  counter-strap. 

Mr.  Lonsdale's  instrument,  Fig.  187,  is  ingenious,  but  too  compli- 
cated and  expensive.  It  is  also  liable  to  the  serious  objection  that 
it  forbids  almost  entirely  the  use  of  bandages,  which,  while  thej  are 
capable  of  doing  great  mischief  when  they  bind  the  limb  too  closely, 
are  capable  also  of  proving  eminently  serviceable  when  they  press 
upon  certain  portions  of  the  limb,  and  not  with  too  much  force. 

Fig.  187. 


Lonsdale's  Apparatus  for  Fractured  Patella. — A  B.  Two  vertical  iron  bars,  each  supporting  a 
horizontal  one  ;  these  horizontal  arms  slide  upon  the  vertical  bars,  but  can  be  secured  at  any  point  by 
the  screws  C  D.  To  the  horizontal  beams  ai'e  attached  other  vertical  rods,  which  are  movable,  and  yet 
fixable  by  screws,  as  at  E.  Finally,  to  each  of  these  last  upright  pieces  is  fixed  an  iron  plate,  F  F,  by 
means  of  a  hinge  point,  which  keeps  the  patella  in  place.  The  foot-piece  is  movable  up  and  down  upon 
the  main  body  of  the  appai'atus,  and  can  be  made  fast  at  any  point,  so  as  to  adapt  the  splint  to  limbs  of 
diflferent  length. 

In  case  the  fracture  is  oblique  or  longitudinal,  it  will  be  only  neces- 
sary to  lay  the  limb  in  a  straight  position,  so  as  to  prevent  that  lateral 
displacement  of  the  fragments  which  has  been  shown  to  occur  when 
the  limb  is  flexed.  It  will  not  be  necessary  to  employ  a  splint,  unless 
the  patient  is  unmanageable  and  demands  restraint,  nor  to  elevate  the 
foot.  After  the  swelling  has  subsided,  a  slight  amount  of  lateral 
pressure,  accomplished  by  a  few  turns  of  a  roller,  with  or  without 
compresses,  as  the  circumstances  may  seem  to  demand,  will  complete 
the  mechanical  part  of  the  treatment. 

I  have  not  mentioned  the  rapid  and  sometimes  intense  inflammation 
to  which  the  knee-joint  is  liable  after  a  fracture  of  the  patella ;  and 
which  is  often  greatly  aggravated  by  the  injudicious  application  of 
bandages.  In  no  instance  ought  the  bandages  to  be  applied  very 
tightly  at  the  first  dressing,  and  during  the  first  five  or  six  days  the 
patient,  ought  to  be  seen  once  or  twice  daily,  and  the  most  prompt 


FEACTUEES    OF    THE    TIBIA.  449 

attention  given  to  any  complaints  of  pain  or  soreness  about  the  knee. 
From  the  beginning,  cloths  moistened  in  cool  water  should  be  con- 
stantly laid  over  the  dressings ;  but  in  case  adhesive  plaster  is  used, 
we  must  be  careful  not  to  soak  the  straps  sufficiently  to  loosen  them. 

If  the  swelling  and  inflammation  increase  rapidly,  it  would  be  far 
better  to  remove  the  straps  or  bandages  altogether  for  a  few  days, 
than  to  take  the  risks  consequent  upon  their  continuance. 

The  anchylosis  which  usually  follows  the  recovery  of  the  patient, 
and  which  is  often  almost  complete,  is  to  be  overcome  by  long  con- 
tinued passive  motion ;  but  great  care  must  be  taken  not  to  rupture 
the  ligament,  as  we  have  already  seen  happen  in  some  cases. 

Dr.  Alfred  C.  Post,  of  the  New  York  Hospital,  has  excised  the 
knee-joint  in  a  case  of  anchylosis  of  long  standing ;  the  limb  being 
so  much  flexed  in  consequence  of  a  comminuted  fracture  of  the  patella, 
as  to  be  not  merely  useless,  but  an  intolerable  incumbrance.  The 
patient  was  a  laboring  man  of  about  forty  years  of  age.  This  operation 
was  made  in  preference  to  amputation,  at  the  request  of  the  man 
himself.^ 


CHAPTER    XXX. 

FEACTUEES   OF  THE  TIBIA. 

Etiology. — Fractures  of  the  tibia  alone  are,  in  a  large  majority  of 
cases,  produced  by  direct  blows,  such  as  the  kick  of  a  horse,  or  a  blow 
from  a  stick  of  wood  ;  in  one  instance  I  have  seen  it  broken  by  a  kick 
from  a  Dutchman's  boot.  It  is  occasionally  broken  by  a  fall  upon  the 
foot,  the  force  of  the  impulse  being  expended  before  the  fibula  gives 
way,  but  almost  always  the  fibula  breaks  at  the  same  moment,  or 
immediately  after  the  fracture  has  taken  place  in  the  tibia. 

Dr.  Proudfoot,  of  jSTew  York,  has  reported  an  example  of  fracture 
of  the  tibia  in  utero^  produced  in  the  sixth  month  of  pregnancy,  by 
violent  pressure  upon  the  abdomen.^ 

Patliology^  Division^  &c. — In  an  analysis  of  twenty  fractures  of  the 
tibia,  five  were  found  to  have  occurred  in  the  upper  third,  seventeen 
in  the  middle  third,  and  three  in  the  lower  third ;  of  which  latter,  one 
was  a  fracture  of  the  malleolus. 

Four  of  the  twenty  are  known  to  have  been  transverse  or  onh^ 
slightly  oblique.  It  is  probable,  also,  that  several  of  the  remainder 
were  transverse.     In  this  respect,  therefore,  fractures  of  the  tibia  alone 

'  Post,  New  York  Med.  Gazette,  vol.  i.  p.  309,  Nov.  1850. 

^  ProTidfoot,  Bost.  Med.  and  Surg.  Journ.,  vol.  sxsv.  p.  268,  1846  ;  from  New  York 
Journ.  Med. 

29 


450  FRACTURES    OF    THE    TIBIA. 

will  be  found  to  differ  materially  from  fractures  of  tbe  tibia  and  fibula ; 
but  it  is  only  in  accordance  with  the  general  observation  that  indirect 
blows  produce  almost  constantly  oblique  fractures,  and  direct  blows, 
somewhat  more  frequently,  transverse. 

Dr.  James  L.  Van  Ingen,  of  Schenectady,  has  reported  a  case  of 
oblique  fracture  of  the  upper  end  of  the  tibia  extending  into  the  joint, 
accompanied  with  a  slight  displacement  of  the  fibula  at  its  upper  end, 
and  also  a  fracture  of  the  external  condyle  of  the  femur.  This  was  in 
the  person  of  a  man  who  had  fallen  from  a  load  of  hay  upon  the  frozen 
ground.!  j^any  other  examples  of  fractures  of  tbe  tibia  extending  into 
the  knee-joint  are  recorded  by  surgeons,  most  of  which  were  compound, 
or  otherwise  seriously  complicated  so  as  to  render  amputation  neces- 
sary, and  the  consideration  of  which  scarcely  belongs  properly  to  a 
treatise  upon  fractures. 

Prognosis. — No  shortening  can  occur  in  this  fracture  unless  one  or 
both  ends  of  the  fibula  are  displaced,  a  complication  which  I  have 
noticed  in  two  instances ;  but  in  neither  case  did  the  shortening  exceed 
one-quarter  of  an  inch. 

Occasionally  the  upper  fragment  has  been  slightly  displaced_  for- 
wards. With  these  exceptions,  and  one  other  of  delayed  union  which  I 
shall  presently  mention,  this  bone  in  my  experience  has  been  found 
to  unite  promptly  and  without  any  appreciable  deformity.  Other 
surgeons  have  noticed  occasionally  that  the  upper  end  of  the  lower 
fragment  has  become  displaced  toward  the  fibula.  Dr.  Donne,  of 
Louisville,  has  reported  an  example  of  delayed  union  in  a  simple, 
transverse  fracture  of  the  upper  end  of  the  tibia.  The  man  was  m- 
temperate.  Ten  weeks  after  the  accident  no  union  had  occurred,  and 
Dr.  Donne  introduced  a  seton,  and  in  about  six  weeks  the  fragments 

were  firm.^  •        i     j 

If  the  fracture  extends  into  either  the  knee  or  ankle-jomt,  the  clanger 
of  anchylosis  is  imminent,  yet  experience  has  shown  that  it  may 
sometimes  be  avoided.  In  the  case  of  Dr.  Van  Ingen's  patient  already 
mentioned,  the  motions  of  the  knee-joint  were  almost  completely  re- 
stored, although  the  accident  was  serious  and  complicated. 

When  the  malleolus  is  broken  off,  it  generally  becomes  slightly  dis- 
placed downwards,  and  in  this  position  a  complete  bony  or  ligamentous 
union  takes  place. 

Treatment.— '^\ie  tendency  to  displacement,  in  a  fracture  of  the  tibia, 
is  so  slight,  if  it  exists  at  all,  that  simple  dressings,  light  splints  of 
felt  or  bmder's  board,  with  rest  in  the  horizontal  posture  upon  a  pillow, 
fulfil  nearly  all  of  the  indications  which  are  usually  present.  The 
foUowino-  cases  will  illustrate  the  usual  course  of  these  accidents. 

Mrs.  W.,  of  Buffalo,  £et.  58,  fell,  Oct.  19,  1848,  striking  on  her  right 
knee,  breaking  the  tibia  transversely  just  below  the  tuberosity. 

The  fall  was  the  result  of  a  misstep  on  level  ground,  and  was  at- 
tended with  only  slight  bruising  of  the  soft  parts.  She  says,  that  on 
attempting  to  rise  she  discovered  what  had  happened,  the  bone  pro- 

>  Van  Ingen,  Report  of  an  action  brought  to  recover  for  surgical  services,  1855. 
2  Donne,  Amer.  Journ.  Med.,  vol.  xxviii.  p.  524;  from  Western  Journ.  Med.  and  Surg., 
Aug.  1841.' 


FEACTUEES    OF    THE    TIBIA.  451 

jecting  very  distinctly,  and  she  pushed  and  pulled  it  into  place  with 
her  own  hands. 

Dr.  Barnes,  who  was  the  family  physician,  requested  me  to  see  it  on 
the  same  day.  Mrs.  W.  was  large,  with  a  leucophlegmatic  tempera- 
ment. The  limb  was  already  swollen  and  oedematous.  The  frag- 
ments were  in  place,  but  motion  and  crepitus  were  distinct. 

I  dressed  the  limb  by  laying  it  upon  a  pillow  outside  of  which  were 
placed  two  broad  deal  splints,  tying  the  whole  snugly  together  Avith 
several  strips  of  bandtige.  At  a  later  period  the  leg  and  thigh  were 
laid  over  a  double  inclined  plane. 

At  the  end  of  six  weeks  all  dressings  were  removed,  and  the  frag- 
ments were  found  to  have  united  firmly,  and  so  perfectly  as  that  the 
point  of  fracture  could  not  be  traced. 

Peter  Hamil,  of  Buffalo,  set.  29,  was  admitted  into  the  hospital  Aug. 
81,  1849,  with  an  injury  to  his  left  leg,  which  had  occurred  two  days 
before.  A  young  surgeon  had  examined  the  limb,  and  thought  the 
femur  was  broken  just  above  the  joint.  He  had  applied  a  roller  from 
the  toes  to  the  thigh ;  and  to  the  thigh  were  applied  lateral  splints. 
These  dressings  were  on  the  limb  at  the  time  of  his  admission,  and 
were  not  removed  until  the  next  day.  I  could  not  then  discover  any 
fracture  or  displacement,  and  the  dressings  were  discontinued,  the  limb 
being  merely  laid  upon  pillows.  After  about  eight  days,  however, 
when  the  swelling  of  the  foot,  consequent  upon  the  bandaging,  had 
subsided,  I  reapplied  side  splints,  believing  it  possible  that  I  might 
have  overlooked  a  transverse  fracture  of  the  lower  end  of  the  femur. 
On  the  26th  of  Sept.,  I  discontinued  them  altogether. 

Oct.  4,  when  examining  the  limb,  I  detected  a  slipping  sensation,  like 
that  produced  in  a  false  joint,  through  the  upper  end  of  the  tibia,  and 
I  now  easily  understood  what  had  been  mistaken  for  a  fracture  of  the 
femur.  It  was  a  transverse  fracture  through  the  upper  end  of  the 
tibia,  and  without  displacement. 

No  splints  were  afterwards  applied,  and  on  the  2oth  of  Nov.,  three 
months  after  admission,  he  was  dismissed,  the  motion  between  the  frag- 
ments having  ceased,  but  the  knee  still  remaining  quite  stiff. 

The  presence  of  inflammation,  with  other  complications,  may,  hov/- 
ever,  occasionally  render  the  treatment  more  difficult  and  the  results 
less  satisfactory. 

John  Mahan,  ^t.  39.  Admitted  to  the  Buffalo  Hospital,  Feb.  16, 
1853,  with  a  compound  fracture  of  the  right  tibia,  near  the  middle  of 
the  leg.  The  bone  was  broken  by  the  kick  of  a  Dutchman.  I  found 
the  limb  much  swollen  and  very  painful,  and  I  laid  it  carefully  over  a 
double  inclined  plane,  and  directed  cold  water  irrigations;  I  also 
directed  morphine  in  full  doses.  The  inflammation  for  several  days 
threatened  the  complete  loss  of  his  limb.  On  the  tenth  day,  the  distal 
end  of  the  upper  fragment  was  projecting  in  front  of  the  lower,  and  I 
depressed  the  angle  of  the  splint  and  made  moderate  pressure  upon  the 
upper  fragment.  On  the  twentieth  day,  the  fragments  were  bent  back- 
wards, and  I  placed  a  compress  behind.  On  the  thirty-seventh  day, 
we  took  the  limb  from  the  inclined  plane  and  trusted  alone  to  side 
splints.     On  the  forty-fifth  day,  we  removed  all  dressings.     The  frag- 


452  FRACTURES    OF    THE    TIBIA. 

ments  had  not  united.  The  limb  was  then  laid  upon  a  pillow,  and  six 
days  later  a  firm  gutta-percha  splint  was  applied  for  the  purpose  of 
steadying  the  bone,  but  the  splint  was  removed  daily  in  order  that  the 
leg  might  be  bathed  and  rubbed.  He  was  allowed  to  sit  up.  On  the 
fifty-ninth  day,  motion  could  still  be  perceived  between  the  fragments, 
and  he  was  directed  to  use  crutches.  On  the  ninety-third  day,  the 
union  was  found  to  be  firm,  the  upper  fragment  remaining  slightly 
displaced  forwards. 

In  case  the  fracture  extends  into  the  knee/joint,  it  is  best  to  lay  the 
limb  upon  pillows  or  in  a  nicely-cushioned  box,  and  nearly  straight. 
ISTo  extension  or  counter-extension  is  necessary  here  any  more  than 
in  other  fractures  of  the  tibia  alone,  nor  are  lateral  splints  or  rollers 
necessary  or  proper  at  first,  as  a  general  rule ;  but  especial  attention 
ought  constantly  be  given  to  the  prevention  of  inflammation,  and  of 
subsequent  anchylosis.  The  omission  to  employ  splints  in  a  case  of 
this  kind  was  charged  against  a  surgeon  in  Vermont  as  evidence  of 
malpractice.  I  am  happy  to  say,  however,  that,  in  this  particular  case, 
he  was  sustained  by  the  testimony  of  the  medical  men  and  by  the 
verdict  of  the  jury;  but  the  attempt  which  the  reporter  has  made  to 
defend  this  as  a  universal  practice  in  fractures  of  the  legs,  or  of  the 
tibia  alone,  is  unfortunate,  and  evinces  a  lack  of  practical  experience.^ 

Whatever  position  is  adopted,  and  whatever  means  of  support  or 
retention  are  employed,  if  bandages  and  splints  are  applied  tightly  or 
injudiciously,  great  suffering  and  irreparable  mischief  to  the  knee-joint 
may  be  the  consequence. 

A  man,  set.  23,  entered  the  Pennsylvania  Hospital  July  18,  1839, 
with  an  oblique  fracture  through  the  head  of  the  tibia.  A  physician 
had  applied  a  bandage  and  splint  to  the  leg,  and  sent  him  twenty  miles 
to  the  city,  and  on  examination  after  his  arrival,  the  whole  limb  as 
high  as  the  groin  was  much  swollen,  red,  and  excessively  painful. 
The  knee-joint  was  distended  and  very  tender.  All  dressings  were 
immediately  removed  and  the  limb  laid  in  a  long  fracture-box,  slightly 
elevated  at  the  foot ;  cool  lotions  were  applied,  and  the  patient  was 
freely  bled,  both  from  the  arm  and  by  the  application  of  leeches.  The 
limb  was  kept  in  this  position  about  six  weeks,  and,  at  the  end  of  two 
or  three  weeks  more  he  was  dismissed  cured.  Dr.  Norris,  who  was 
the  hospital  surgeon  in  attendance,  has,  in  his  report  of  the  case,  very 
properly  taken  this  occasion  to  warn  surgeons  of  the  danger  of  exces- 
sive bandaging  and  splinting  in  this  kind  of  fracture,  as  well  as  in  all 
other  fractures  of  the  lower  extremities.^ 

Fractures  of  the  malleolus  demand  only  that  the  limb  should  be  laid 
upon  its  outer,  or  fibular  side,  with  the  foot  so  supported  as  that  it 
shall  incline  inwards  toward  the  tibia.  In  this  simple  disposition  of 
the  limb  we  have  done  all  that  can  be  done  by  any  mechanical  con- 
trivance toward  approaching  the  lower  fragment  to  the  shaft  from 
which  it  has  been  broken. 

'  Boston  Med.  Journ.,  vol.  liv.  p.  1,  March,  1856. 

^  Norris,  Amer.  Journ.  of  Med.  Sci.,  vol.  xxiii.  p.  291. 


FEACTURES    OF    THE    FIBULA. 


453 


CHAPTER    XXXI 


FEACTURES   OF  THE  FIBULA. 


Causes. — In  a  record  of  thirty-two  cases,  I  Lave  been  able  to  ascer- 
tain the  cause  satisfactorily  in  eighteen,  of  which  number  three  were 
the  results  of  falls  directly  upon  the  bottom  of  the  foot,  four  of  a  slip 
of  the  foot  in  walking  on  level  ground,  or  on  ground  only  slightly 
irregular,  and  twelve  of  direct  blows. 

Pathology. — In  all  of  the  fractures  which  have  been  produced  by 
falls  upon  the  bottom  of  the  foot,  and  in  all,  except  one,  produced  by 
a  slip  of  the  foot,  the  accident  was  accompanied  with  a  dislocation  of 
the  ankle;  the  foot  being  turned  outwards.  In  the  one  exceptional 
case  mentioned,  the  dislocation  may  also  have  occurred,  but  the  fact 
is  not  known. 

Both  Malgaigne  and  Dupuytren  have  noticed  a  dislocation  in  the 
opposite  direction,  or  a  turning  of  the  foot  inwards,  more  often  than  a 
turning  outwards.  I  cannot  think  their  observations  were  carefully 
made. 

Moreover,  in  at  least  seven  of  the  twelve  fractures  produced  by 
direct  blows  the  tibia  has  been  thrown  more  or  less  inwards,  and  con- 
sequently the  foot  has  turned  out. 

In  twenty-four  examples  the  fracture  of  the  fibula  has  taken  place 
within  from  two  to  five  inches  of  the  lower  end  of  the  bone.     Twice  I 
have  found  the  external  malleolus  broken  off,  and  seven 
times  the  internal  malleolus. 

Four  of  the  fractures  occurring  in  consequence  of 
direct  blows  were  compound,  and  one  was  also  com- 
minuted. 

Prognosis. — In  a  majority  of  cases,  where  the  fibula 
has  been  broken  from  two  to  five  inches  above  the 
lower  end,  the  fragments  have  united  inclined  toward 
or  resting  against  the  tibia;  occasionally  I  have  seen 
them  displaced  backwards.  Once  the  fibula  refused  to 
unite  altogether. 

The  malleoli  have  generally  united  nearly  or  quite 
in  place,  but  in  two  instances  the  external  malleolus 
has  been  found  displaced  very  much  downwards. 

Of  the  compound  fractures,  two  required  amputation, 
one  was  treated  by  resection  of  the  lower  end  of  the 
tibia,  and  one  died  without  any  operation.  Douglas 
has  reported  a  case  of  compound  dislocation  with  frac- 
ture of  the  fibula,  which  being  reduced,  he  was  able  to 
save  the  limb,  but  not  without  much  difficulty,  and  the 


Fig.  188. 


Fracture  of  fibula 
near  lower  ead. 


454  FEACTURES    OF    THE    FIBULA. 

ankle  remained  stiff.'  Other  surgeons  have  met  with  similar  success, 
but  I  shall  refer  to  this  subject  again  under  the  head  of  compound 
dislocations. 

Of  those  which  recovered,  twenty- eight  in  number,  ten  have  been 
found  to  have  more  or  less  unnatural  prominence  of  the  internal  mal- 
leolus, and  in  two  of  these  the  malleolus,  or  lower  end  of  the  tibia, 
projects  very  much.  In  nearly  all  of  th^se  examples  the  foot  appears 
somewhat  inclined  outwards.  ^ 

Generally  the  ankle-joint  has  remained  stiff  for  some  time  after  the 
bandages  have  been  removed ;  and  probably  in  all  cases  in  which  the 
accident  was  accompanied  with  a  dislocation  of  the  tibia.  But  this 
stiffness  has  usually  disappeared  after  a  few  weeks  or  months.  Twice 
I  have  noticed  considerable  stifihess  after  about  six  months;  three  times 
after  one  year;  in  one  case  after  two  years,  and  in  one  case  after  twenty 
years  the  ankle  would  occasionally  swell  and  become  quite  stiff.  In 
one  case  it  remained  almost  immovable  after  twenty  years ;  and  in  a 
still  more  remarkable  instance,  I  examined  the  limb  thirty  years  after 
the  accident,  when  the  man  was  sixty-three  years  old,  and  although 
there  existed  no  swelling  or  deformity,  yet  this  leg  was  not  as  muscu- 
lar as  the  other,  and  he  declared  that  up  to  this  time  the  ankle  re- 
mained quite  tender  to  the  touch,  and  that  occasionally  it  became 
painful. 

When  I  come  to  speak  of  dislocations  of  the  ankle,  I  shall  adopt 
the  usual  nomenclature,  and  shall  name  all  those  dislocations  in  which 
the  tibia  projects  inwards  from  the  foot,  "inward  dislocations  of  the 
tibia,"  yet  I  have  some  doubts  as  to  the  propriety  of  this  appellation. 
This  accident  seems  to  me  to  have  been  in  general  rather  a  lateral 
rotation  of  the  foot,  or  of  the  astragalus,  upon  the  lower  articulating 
surfaces  of  the  tibia  and  fibula.  Of  all  the  ginglymoid  joints,  the 
ankle  approaches  most  nearly  in  form  to  a  ball  and  socket  joint,  in 
consequence  especially  of  the  marked  prolongations  of  the  malleolus 
internus  and  externus.  In  other  ginglymoid  articulations  lateral  dis- 
placements are  not  unfrequent,  but  lateral  rotation  can  scarcely  by 
any  accident  occur.  Here,  however,  the  reverse  holds  true ;  lateral 
displacement  is  difficult,  while  lateral  rotation  is  comparatively  easy 
of  accomplishment. 

The  majority  of  cases  which  occur  involving  a  disturbance  of  the 
relative  position  of  the  ankle-joint  surfaces,  are,  I  am  satisfied,  of  this 
latter  character,  viz.,  lateral  rotations  within  the  capsule,  rather  than 
true  dislocations ;  and  although  the  restoration  of  the  joint  surfaces 
to  position  is,  in  general,  easily  accomplished ;  yet,  in  consequence  of 
either  a  fracture  of  the  fibula,  or  malleolus  internus,  or  of  a  rupture  of 
the  internal  lateral  ligaments,  it  will  almost  always  happen  that  some 
deformity  will  remain.  The  fragments  of  the  fibula  will  fall  inwards 
toward  the  tibia,  and  the  foot,  unsupported  by  either  its  fibula  or  its 
internal  ligaments,  will  incline  perceptibly  outwards.  Nor  can  this 
be  prevented,  usually,  by  any  mechanical  contrivance.  Indeed,  it 
would  be  easy  to  demonstrate,  as  I  have  often  done  to  my  pupils,  that 

'  Boston  Med.  and  Surg.  Journ.,  vol.  xxxiv.  p.  336,  from  Southern  Journ.  of  Med. 


FRACTURES    OF    THE    FIBULA.  455 

even  Dupujtren's  splint,  usually  employed  in  this  accident,  must  fail 
of  success  in  a  great  majority  of  cases ;  since  the  subsequent  deformity 
is  due,  less  to  the  fracture  of  the  fibula  and  its  consequent  displace- 
ment, than  to  the  loss  of  the  internal  ligaments,  which  loss  nature  can 
seldom  fully  repair.  The  whole  apparatus  of  the  joint  has  suffered 
greatly,  and  its  form  and  functions,  therefore,  are  not  likely  to  be 
completely  restored,  whether  the  fibula  has  participated  in  the  injury 
or  not.  As  further  evidence  of  the  correctness  of  this  view,  I  will 
state  that  in  three  of  the  examples  in  which  I  have  found  the  fractured 
fibula  united  and  resting  against  the  tibia,  the  motions  of  the  ankle- 
joint  have  been  completely  recovered. 

If,  however,  it  were  true  that  a  fracture  and  displacement  of  the 
fibula  is  the  sole  or  essential  cause  of  the  subsequent  deformity,  it 
would  still  be  found  often  impracticable  to  avoid  the  maiming,  since 
it  would  still  remain  impossible  to  lift  the  broken  ends  from  the  tibia, 
against  which,  or  in  the  direction  toward  which,  they  are  so  prone  to 
fall.  Inversion  of  the  foot  does  not  accomplish  it,  nor  have  I  ever 
been  able  to  make  anything  but  the  most  trivial  impression  upon  the 
upper  end  of  the  lower  fragment  by  pressure  upon  the  lower  extremity 
of  the  fibula. 

I  think  too  much  confidence  has  been  placed  in  the  efficiency  of 
"Dupuytren's  splint."  I  believe,  indeed,  that  this  splint  ought  gene- 
rally to  be  preferred  as  a  means  of  support  and  retention  after  this 
accident,  and  I  have  myself  usually  employed  it;  but  I  doubt  whether 
it  is  able  to  accomplish  more  than  a  moiety  of  all  that  its  illustrious 
inventor  proposed. 

Treatment. — I  have  already  expressed  my  preference  for  Dupuytren's 
mode  of  dressing  as  a  general  practice,  and  especially  would  I  give  it 
the  preference  whenever  the  accident  has  been  accompanied  with  an 
outward  luxation  of  the  foot,  and  a  consequent  rupture  of  the  internal 
lateral  ligaments,  or  a  fracture  of  the  internal  malleolus. 

This  mode  of  dressing  is  essentially  as  follows: — 

A  pad,  or  long  junk,  made  of  a  piece  of  cotton  cloth,  stuffed  with 
cotton  batting,  is  constructed  of  sufficient  length  to  extend  from  the 
condyles  of  the  femur  to  a  point  just  above  the  malleolus  internus. 
This  pad  must  be  about  five  or  six  inches  in  width,  and  thicker  by 
one  or  two  inches  at  its  lower  than  its  upper  end.  This  is  to  be  laid 
upon  the  inside  of  the  leg,  with  its  base  or  thickest  portion  resting 
against  the  tibia  just  above  the  internal  malleolus.     Over  this  pad  is 

Fig.  189. 


Dupuytren's  splint  modified. 


to  be  placed  a  long  firm  splint,  extending  also  from  above  the  knee  to 

three  inches  beyond  the  bottom  of  the  foot.     With  a  few  turns  of  a 

oiler  the  upper  end  of  the  splint  will  now  be  made  fast  to  the  knee, 


456 


FEACTUEES    OF    THE    FIBULA. 


and  with  a  second  roller  the  lower  end  must  be  secured  to  the  foot. 
The  application  of  this  last  bandage  requires,  however, 
some  care  in  its  adjustment.  Its  purpose  is  simply  to 
rotate  the  foot  inwards,  while  at  the  same  time  the  tibia  is 
pressed  outwards ;  and  to  this  end  it  must  be  applied  in 
the  form  of  a  figure-of-8  over  both  splint  and  foot,  em- 
bracing alternately  the  hee^  and  the  instep.  In  order  to 
be  effectual,  it  must  be  drawn  pretty  firmly,  and  no  por- 
tion of  the  bandage  must  pass  higher  than  the  malleolus 
externus.  In  some  surgical  books  I  have  seen  this  appa- 
ratus represented  with  a  roller  embracing  the  whole  length 
of  the  leg;  and  in  others  it  is  represented  as  encircling 
the  limb  two  or  three  inches  above  the  malleolus  (Fig. 
190),  but  it  is  evident  that  these  modes  of  dressing 
must  defeat  the  great  object  which  Dupuytren  had  in  view, 
namely,  the  throwing  out  of  the  upper  end  of  the  lower 
fragment. 

When  the  limb  is  thus  dressed,  the  knee  may  be  flexed 
and  the  leg  laid  upon  its  outside,  supported  by  a  pillow, 
or  upon  its  inside,  as  in  the  accompanying  engraving. 
(Fig.  191.) 

If  it  is  only  a  fracture  of  the  external  malleolus,  or  if 
the  fracture  has  occurred  in  the  middle  or  upper  third  of  the  bone, 
this  treatment  is  no  longer  appropriate,  and  it  will  generally  be  found 
sufficient  to  place  the  limb  at  rest  for  a  few  days  upon  a  suitable  cush- 
ion or  upon  a  pillow. 

Fig.  191. 


Dupuytren's 
splint  incor 
rectly  applied. 


Dupuytren's  splint  as  originally  applied  by  himself. 

It  is  scarcely  necessary  to  say  that,  since  after  this  accident  anchy- 
losis is  so  frequent,  early  and  unremitting  attention  should  be  given 
to  the  establishment  of  passive  motion  in  the  joint.  Indeed,  I  cannot 
bat  think  that  a  desire  to  accomplish  the  indications  recognized  and 
urged  by  Dupuytren  has  led  to  the  neglect  of  the  indication  which 
ought  to  have  been  regarded  as  of  equal,  if  not  of  the  greatest,  import- 
ance, namely,  the  prevention  of  contractions  and  adhesions  around  and 
between  the  joint  surfaces. 

As  a  general  rule,  the  dressings  ought  to  be  wholly  laid  aside  by  the 
end  of  the  third  or  fourth  week;  and  although  it  may  be  well  for  a 
somewhat  longer  time  to  keep  the  foot  turned  in  by  having  it  properly 
supported  as  it  lies  upon  the  pillow,  yet  after  this  date  I  regard  the  use 
of  splints  and  bandages  as  only  pernicious. 


FEACTURES    OF    THE    TIBIA    AND    FIBULA.  457 


CHAPTEE    XXXII. 

FRACTURES   OF  THE   TIBIA  AND  FIBULA. 

Causes. — Probably  four-fifths  of  these  fractures  are  the  results  of 
direct  blows,  or  of  crushing  accidents,  such  as  the  kick  of  a  horse,  the 
passage  of  a  loaded  vehicle  across  the  limb,  the  fall  of  heavy  stones  or 
timbers,  &c. 

In  an  analj'-sis  of  eighty -three  cases,  I  find  the  bones  broken  in  the 
upper  third  from  a  direct  cause  four  times,  and  from  an  indirect  cause 
once.  In  the  middle  third  thirty-three  have  been  referred  to  a  direct 
cause,  and  one  to  an  indirect;  and  in  the  lower  third  thirty-three  to  a 
direct  cause,  and  twelve  to  an  indirect.  An  observation  which  does 
not  sustain  the  remark  of  Malgaigne,  based  upon  his  analysis  of  sixty- 
seven  cases,  that  fractures  of  the  upper  third  are  produced  by  direct 
causes  alone,  those  of  the  middle  third  much  more  frequently  by  indi- 
rect causes,  and  that  those  of  the  lower  third  are  especially  due  to 
indirect  causes.  Direct  causes  produce  a  large  majority  of  the  frac- 
tures of  the  lower  third,  but  the  proportion  is  smaller  tban  in  the 
middle  third. 

Of  the  indirect  causes,  falls  upon  the  feet  from  a  considerable  height 
— as  from  a  scafiblding,  or  from  the  top  of  a  building — are  by  far  the 
most  common.  Four  times  I  have  found  the  bones  broken  by  muscu- 
lar action  alone,  as  in  the  following  example: — 

Mrs.  W.,  of  Buffalo,  aged  about  twenty-five  years,  and  weighing  at 
this  time  nearly  two  hundred  pounds,  was  descending  her  door-steps 
with  an  infant  in  her  arms,  when,  the  steps  being  covered  with  ice,  she 
slipped  and  fell,  breaking  her  right  leg  just  above  the  ankle.  Mrs.  W. 
says  she  felt  and  heard  the  bones  snap  before  she  touched  the  steps. 
Of  this  she  is  certain. 

We  found  the  tibia  broken  obliquely,  the  fragments  being  quite 
movable,  but  not  much,  if  at  all,  displaced.  The  limb  was  dressed 
with  a  carefully-moulded  and  well-padded  gutta-percha  splint,  and 
then  laid  in  a  pillow  upon  the  bed.  Mrs.  W.  experienced  unusual 
pain  from  the  fracture  for  several  days,  for  the  relief  of  which  we  were 
compelled  at  times  to  permit  her  to  inhale  chloroform.  She  was  of  a 
nervous  temperament,  and  had  frequently  resorted  to  chloroform 
before  to  relieve  neuralgic  pains.  The  limb  became  very  much 
swollen,  and  remained  so  for  a  week  or  two.  No  extension  was  ever 
employed. 

Within  the  usual  time  the  bones  united  in  perfect  apposition,  and 
in  about  four  months  she  was  able  to  walk  without  any  halt. 

Pathology,  Symptoms,  dec. — We  have  seen  that  fractures  of  both 


458  FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 

bones  through  some  part  of  the  lower  third  are  most  frequent.  Thus, 
of  one  hundred  and  forty-two  fractures,  eleven  belonged  to  the  upper 
third,  forty  to  the  middle,  and  eighty-five  to  the  lower.  In  six  cases 
the  two  bones  were  broken  in  different  divisions.  It  is  probable  that 
in  this  analysis  some  errors  have  occurred,  and  that  in  a  larger  pro- 
portion than  here  stated,  the  two  bones  have  given  way  at  opposite 
extremities,  since  it  is  often  difficult,  a.nd  sometimes  quite  impossible 
to  determine  precisely  where  the  fibula  is  broken ;  but  the  analysis  is 
sufficiently  correct  to  illustrate  the  much  greater  frequency  of  fractures 
of  the  lower  third,  and  also  the  fact  that  the  two  bones  generally 
break  nearly  on  the  same  level ;  usually  the  point  of  fracture  in  the 
tibia  is  between  two  and  three  inches  above  the  joint,  where  the  bone 
is  the  weakest. 

In  an  examination  of  twenty  museum  specimens  I  have  found  both 
bones  broken  at  the  same  point,  or  within  two  or  three  inches  of  the 
same  point,  sixteen  times,  and  at  extreme  points,  four  times  ;  and  in 
these  last  examples,  the  tibia  has  always  been  broken  in  the  lower 
third,  while  the  fibula  has  been  broken  in  the  upper  third. 

In  thirteen  of  the  fractures  mentioned  as  belonging  to  the  lower 
third,  only  the  malleolus  of  the  tibia  was  broken,  while  the  fibula  was 
broken  two  or  three  inches  above  its  lower  end.  Some  of  these  were, 
perhaps,  examples  of  dislocation  of  the  ankle. 

I  have  seldom  seen  a  transverse  fracture  of  the  tibia  except  in  its 
lower  or  upper  extremity,  in  the  expanded  portions  of  the  bone,  and 
even  in  those  examples  which  we  are  accustomed  to  call  transverse, 
because  they  are  sufficiently  so  to  prevent  any  sliding  or  overlapping 
of  the  fragments,  there  has  existed,  generally,  a  marked  inclination  of 
the  line  of  fracture  in  one  direction  or  another. 

The  examples  of  fracture  produced  by  muscular  action  have,  with- 
out an  exception,  occurred  in  adults.  Three  of  them  were  in  the  lower 
third  of  the  leg,  and  one  in  the  middle  third.  I  think  they  were,  all 
of  them,  nearly  transverse,  since  they  never  became  much,  if  at  all 
displaced. 

Most  of  the  fractures  of  the  tibia  produced  by  falls  upon  the  feet 
are  very  oblique,  and  the  direction  of  the  fracture  is  generally  down- 
wards, forwards,  and  inwards;  but  I  have  found  almost  every  con- 
ceivable variation  from  this  general  rule. 

The  fracture  in  the  fibula  is  even  more  constantly  oblique  than  the 
fracture  in  the  tibia;  but  this  is  a  point  of  very  little  practical  conse- 
quence, and  one  which  we  can  seldom  determine  positively,  unless  one 
of  the  fractured  ends  protrudes  through  the  flesh. 

Compound  and  comminuted  fractures  are  more  frequent  here  than  i 
in  any  other  of  the  bones  of  the  body.  My  tables,  which  have  rejected 
all  fractures  demanding  immediate  amputation,  most  of  which  are 
compound,  do  not  for  this  reason  give  a  just  idea  of  their  proportion 
to  simple  fractures;  yet  even  in  these  tables  of  one  hundred  and 
forty-four  fractures,  fifty-four  were  compound,  and  also,  generally, 
more  or  less  comminuted.  Of  eighty  cases  reported  by  W.  W.  Mor- 
land,  of  Boston,  from   the  Massachusetts  General  Hospital,  and  in. 


FEACTURES    OF    THE    TIBIA    AND    FIBULA.  459 

which  the  character  of  the  accident  is  recorded,  thirty-nine  were  com- 
pound.^ 

The  symptoms  indicating  a  fracture  of  both  bones  of  the  leg  are  the 
same  which  are  usually  present  in  other  fractures,  namely,  mobility, 
crepitus,  shortening  of  the  limb,  distortion,  swelling,  &c.     Generally 

Fig.  192. 


Compound  and  comminuted  fracture  of  the  leg. 

the  lower  end  of  the  upper  fragment  projects  in  front,  and  can  be  seen 
or  felt;  but  in  some  instances  the  swelling  follows  so  rapidly  that  it  is 
impossible  to  feel  distinctly  the  point  of  fracture,  and  its  existence  can 
only  be  determined  by  the  crepitus,  mobility,  and  shortening  of  the 
limb,  or,  perhaps,  by  the  marked  deformity  or  deviation  from  the 
natural  axis. 

The  shortening,  where  it  exists  at  all,  varies  at  the  first  from  a  line 
or  two  to  a  half  or  three-quarters  of  an  inch.  Generally,  it  is  about 
half  an  inch. 

Prognosis. — The  average  period  of  perfect  union  in  twenty-nine 
cases,  including  those  in  which  union  was  delayed  by  extraordinary 
causes  beyond  the  usual  time,  was  forty  days.  The  general  average 
■under  ordinary  circumstances  may  be  stated  at  about  thirty  days. 

Union  has  been  dela3^ed  in  six  cases,  four  of  which  were  simple 
fractures,  and  two^were  compound.  The  longest  period  was  seventeen 
weeks. 

F.  C.  T.,  of  Erie  Co.,  IST.  Y.,  set.  35,  broke  his  right  leg  in  jumping 
from  a  buggy  in  June,  1852.  Fractures  oblique  in  both  bones;  near 
the  lower  end  of  the  upper  third;  simple. 

The  limb  was  dressed  with  lateral  splints,  made  of  white  wood,  and 
with  compresses  and  bandages,  and  then  laid  upon  a  pillow. 

Eight  weeks  after  the  fracture  had  occurred,  the  gentlemen  in 
attendance  wished  me  to  see  the  limb  with  them.  I  found  Mr.  T.  still 
in  bed,  and  the  fragments  not  at  all  united. 

Mr.  T.  had  enjoyed  average  health  heretofore,  but  he  was  never 
very  robust.  When  I  was  called  to  see  him  he  looked  pale;  his  skin 
was  cold  and  moist,  pulse  120,  and  appetite  poor.     The  broken  leg 

'  Transao.  of  Mass.  Med.  Soo.  for  1840  ;  Fractures,  by  A.  L,  Pierson. 


460  FEACTURES    OF    THE    TIBIA    AND    FIBULA. 

and  foot  were  greatly  swollen.  The  swelling  was- cedematous.  Con- 
siderable excoriations  existed  on  the  back  of  the  leg.  The  fragments 
were  quite  movable,  and  were  overlapped  three-quarters  of  an  inch. 

We  agreed  that  the  patient  ought,  as  soon  as  possible,  to  be  got  out 
of  bed,  so  as  to  enable  him  to  recover  his  strength,  which  had  sadly- 
declined.  To  this  end,  a  gutta-percha  splint  was  made  to  fit  accurately 
the  whole  length  of  the  leg;  and,  havilbg  attached  a  large  number  of 
tapes,  it  was  to  be  secured  upon  the  limb.  Several  times  each  day  it 
was  to  be  removed,  and  the  limb  bathed  with  brandy  and  water. 
Gradually,  also,  the  limb  was  to  be  brought  down  to  the  floor,  and  the 
patient  be  made  to  sit  up,  and,  as  soon  as  possible,  he  was  to  walk 
with  crutches,  or  to  ride. 

Nov.  4,  1852,  Mr.  T.  visited  me  at  Buffalo.  The  directions  had 
been  followed  implicitly.  About  two  weeks  after  my  visit,  he  rode 
out,  and  in  about  nine  weeks,  or  seventeen  weeks  from  the  time  of 
the  fracture,  the  bones  were  found  united.  His  health  and  strength 
were  quite  restored,  and  the  limb  was  no  longer  cedematous.  It  was 
found  to  be  straight,  or  with  only  a  slight  projection  of  the  upper 
fragment  in  front  of  the  lower,  and  shortened  three-quarters  of  an 
inch. 

A  gentleman,  set.  33,  from  Bergen,  N.  Y,,  was  struck  by  a  billet  of 
wood  on  the  3d  of  August,  1856,  breaking  his  left  leg  nearly  trans- 
versely, three  and  a  half  inches  above  the  joint.  The  fracture  was 
simple.  A  surgeon  was  called  immediately,  who  applied  bandages  and 
side  splints,  and  then  laid  the  limb  over  a  double  inclined  plane.  At 
the  end  of  six  weeks  the  dressings  were  removed,  but  the  bones  had 
not  united.  Seven  months  after  the  accident,  this  gentleman  consulted 
me  at  Buffalo.  I  found  him  in  good  health,  but  no  union  had  yet 
taken  place.  This  is  the  only  example,  except  where  amputation  or 
death  interposed,  in  which  the  union  has  been  so  long  delayed  as  to 
entitle  it  to  be  considered  as  a  case  of  non-union.  My  own  observation 
would,  therefore,  incline  me  to  think  that,  while  non-union  is  a  rare 
event  in  fractures  of  the  leg,  delayed  union  is  more  frequent  than  in 
most  other  fractures. 

It  has  once  occurred  to  me  to  see  a  complete  non-union  of  the  fibula 
after  a  period  of  several  years,  while  the  tibia  had  united  well.  This 
circumstance  occasioned  no  inconvenience  to  the  patient,  and  was  not 
known  to  him  until  I  had  made  the  discovery. 

A  little  more  than  one-half  of  those  cases  in  which  an  accurate 
note  of  the  result  has  been  made,  have  been  found  to  be  more  or  less 
shortened  by  overlapping,  namely,  sixty-one  cases  out  of  one  hundred 
and  ten.  The  greatest  amount  of  shortening  in  any  one  case  has  been 
one  inch  and  a  half;  and  the  average  shortening  of  the  sixty-one  cases 
has  been  half  an  inch  and  a  fraction  over.  This  analysis  includes  both 
simple  and  compound  fractures;  but  a  pretty  large  proportion  of  the 
simple  fractures  have  also  been  found  shortened,  as  in  the  following 
extreme  illustration. 

John  Granger,  of  Hungerford,  England,  aet,  43,  was  tripped  by 
a  stone   while    walking,  breaking  his  right   leg  through   its   lower 


FEACTUEES    OF    THE    TIBIA    AND    FIBULA.  461 

tbircl.  Fracture  simple  and  oblique.  It  was  treated  by  Eichard 
Barker,  surgeon,  of  Hungerford,  England.  He  employed  only  side 
splints. 

Two  years  after,  I  found  the  leg  shortened  one  inch,  the  upper 
fragment  riding  upon  the  front  and  inner  side  of  the  lower. 

Generally,  when  a  shortening  has  occurred,  I  have  found  the  upper 
fragment  in  front  of  the  lower,  and  often er  a  little  upon  the  inner  than 
upon  the  outer  side. 

The  deviation  from  the  natural  axis  of  the  limb  has  been  noticed  by 
rae  in  a  good  many  instances.  Seven  times  the  lower  part  of  the  limb 
has  fallen  backwards,  and  five  times  it  has,  in  a  degree  much  less 
marked,  inclined  inwards.  Once  I  have  seen  it  inclined  outwards,  and 
tiwice  forwards. 

Ulcers  upon  the  back  of  the  heel,  seen  by  rae  five  times,  as  a  result 
of  undue  pressure  upon  this  part,  have,  however,  been  presented  but 
once  in  a  case  of  simple  fracture. 

It  is  not  very  unusual  to  find,  also,  over  the  exact  point  of  frac- 
ture, and  after  the  lapse  of  several  months,  or  even  years,  an  ulcer,  or 
sinus,  which  is  due  sometimes  to  the  presence  of  a  small  fragment  of 
bone  which  has  remained  in  the  wound  from  the  time  of  the  accident, 
or  to  a  thin  scale  which  has  subsequently  exfoliated.  In  other  cases 
it  is  due  to  the  prominence  of  the  salient  angle  when  the  lower  part 
of  the  limb  inclines  considerably  backwards,  and  in  still  other  cases, 
no  doubt,  to  the  general  dyscrasy  of  the  system,  and  to  the  same 
causes  which  produce  chronic  ulcers  in  the  lower  extremities  where 
only  the  skin  has  been  originally  injured.  I  have  reported  elsewhere 
examples  of  this  complication  existing  after  five  months,  two,  and 
three  years,^  and  in  the  remarkable  case  which  I  shall  now  briefly 
relate,  an  ulcer  existed  at  the  end  of  twenty-three  years, 

Thurstone  Carpenter,  when  four  years  old,  received  an  injury, 
breaking  both  bones  of  one  of  his  legs  near  its  middle.  The  fracture 
was  compound.  It  was  dressed  and  treated  by  an  excellent  surgeon, 
then  residing  in  this  city,  but  long  since  dead. 

Twenty-three  years  after  the  accident,  Mr.  Carpenter  called  upon 
me  on  account  of  a  paralysis  of  his  lower  extremities,  which  had 
recently  occurred.  He  stated  that  from  the  time  of  the  fracture  until 
within  about  one  year,  an  open  ulcer  had  existed  over  the  seat  of 
fracture,  and  that  soon  after  it  had  closed  over  completely  he  began 
to  lose  the  use  of  his  limbs.  During  the  time  it  was  open,  small  scales 
of  bone  have  frequently  been  thrown  off.  The  limb  is  half  an  inch 
shorter  than  the  other,  but  straight. 

Two  years  since,  I  amputated  the  leg  of  a  gentleman  residing  in 
Quincy,  Chatauqua  Co.,  N.  Y.,  which  had  been  broken  a  little  above 
the  ankle  in  1844:.  The  accident  was  produced  by  the  wheel  of  a 
carriage,  and  the  skin  was  considerably  lacerated.  The  wounds,  how- 
ever, healed  kindly,  and  the  broken  bones  united  in  the  usual  time 
without  any  apparent  deformity,  but  the  limb  continued  swollen  and 

'  Trans.  Amer.  Med.  Assoc.     Report  on  Deformities  after  Fractures. 


462  FRACTUEES    OF    THE    TIBIA    AND    FIBULA. 

painful,  until  finally  suppuration  took  place.     After  twelve  years  of 
great  suffering,  I  amputated  the  leg  near  its  middle,  from  wliicli  time  !i 
he  made  a  speedy  recovery.     I  found  the  lower  end  of  the  tibia 
inflamed,  softened,  and  expanded,  and  containing  in  its  interior  about 
three  ounces  of  pus,  but  no  sequestrum. 

Anchylosis  of  the  knee  or  ankle-jorpt  may  follow  as  a  result  of  the  [ 
accident  or  of  improper  treatment ;  an^  at  one  or  both  of  these  joints  \ 
I  have  found  more  or  less  anchylosis  at  the  end  of  nine  months,  one 
year,  six  years,  twenty-five,  thirty,  and  forty  years.  Generally,  how- 
ever, it  disappears  in  a  few  weeks,  and  seldom  remains,  to  any  con- 
siderable extent,  in  the  knee-joint  after  the  dressings  have  been 
removed  two  or  three  weeks ;  but  an  Irishman  called  upon  me  in 
1853  whose  leg,  had  been  broken  about  three  inches  below  the  knee- 
joint  six  years  before.  It  was  a  simple  fracture.  A  surgeon  in 
Ireland  had  treated  the  case.  I  found  the  limb  shortened  one  inch 
and  a  half,  the  fragments  being  overlapped  and  displaced  backwards 
at  the  point  of  fracture.  The  knee  was  also  partly  anchylosed.  I 
could  not  learn  what  the  treatment  had  been. 

In  other  cases,  where  no  permanent  anchylosis  has  followed,  the 
ankle-joint  has  been  occasionally  painful,  and  subject  to  swellings, 
after  the  lapse  of  many  years. 

After  all  that  has  been  said  as  to  the  occasionally  serious  nature  of 
the  consequences  of  these  accidents,  as  shown  in  the  shortening  of  the 
limbs,  in  their  deviations  from  their  natural  axes,  in  the  stiff  ankles, 
ulce'rs  and  abscesses,  it  must  still  be  admitted  that  in  another  point  of 
view  these  results  are  not  extraordinary,  and  may  hereafter  continue 
to  be  fairly  anticipated  in  a  certain  proportion  of  cases,  even  under 
the  best  management;  since  it  must  be  understood  that  more  fractures 
of  the  leg  are  attended  with  serious  complications  than  of  any  other 
limb ;  and  that  while  many  produce  death  rapidly  from  the  severity 
of  the  shock,  and  very  many  are  condemned  at  once  to  amputation,  a 
large  number  of  those  which  are  saved  have  been  in  that  condition 
which  has  rendered  the  application  of  bandages  or  splints  impossible 
for  many  days.  Indeed,  not  a  few  of  these  crooked  limbs  may  still  be 
presented  as  real  triumphs  of  the  art  of  surgery,  inasmuch  as  by 
consummate  skill  alone  have  they  been  saved. 

Ireatment. — Without  being  able,  in  a  case  which  presents  so  many 
forms  and  complications,  to  establish  any  rule  of  universal  applica- 
tion, I  nevertheless  do  not  hesitate,  after  considerable  experience,  in 
declaring  a  plan  of  treatment  which  in  my  opinion  ought  to  be  adopted 
with  only  occasional  exceptions,  that  is,  I  mean  to  say,  in  simple 
fractures.  The  plan  to  which  we  choose  to  give  so  general  a  prefer- 
ence is  well  known  as  that  recommended  and  practised  by  Pott,  the 
distinguished  surgeon  of  St.  Bartholomew's  Hospital ;  and  with  only 
slight  modifications,  it  will  be  found  applicable  to  probably  nine- 
tenths  of  all  the  simple  fractures  of  the  leg,  and  to  some  of  the  com- 
pound fractures. 

The  apparatus  will  consist  of  two  splints  with  pads  and  bandages. 

First  we  are  to  construct  a  splint  (Fig.  193),  made  of  a  thin  piece  of 


FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 


463 


board,  long  enough  to  extend  frona  a  little  above  the  knee,  to  a  point 
two  inches  beyond  the  sole  of  the  foot,  about  seven  inches  in  width,  and 
reaching  forwards  at  the  lower  end,  so  as  to  support  the  foot.  This 
splint  is  to  be  covered  heavily  with  cotton  batting  in  order  that  it 
may  fit  all  the  inequalities  of  the  outer  side  of  the  leg  and  foot,  taking, 
however,  especial  care  that  there  should  be  a  depression  at  a  point 
corresponding  to  the  external  malleolus,  so  deep  as  that  even  when 
the  limb  is  bound  down  to  the  splint  the  malleolus  shall  not  touch. 
The  splint  with  its  padding  must  then  be  covered  with  cotton  cloth 
neatly  sewed  on. 

The  remaining  splint  may  be  made  of  binder's  board,  felt,  or  gutta 
percha ;  but  in  either  case  it  need  not  extend  higher  than  the  bend  of 
the  knee  or  lower  than  the  upper  margin  of  the  malleolus  internus, 

Fi^.  193. 


Long  splint  for  treatment  of  a  fracture  of  the  leg  in  Pott's  position. 

unless  the  fracture  should  be  near  one  of  these  extremities ;  and  in 
case  it  does  extend  lower,  the  same  precautions  must  be  taken  to 
protect  the  malleolus  internus  from  pressure.  Whichever  also  of  the 
materials  is  employed,  the  splint  never  ought  to  be  applied  directly 
to  the  skin,  but  a  thin  pad  made  of  a  few  layers  of  cotton  sheeting 
covered  with  cotton  cloth  must  be  laid  underneath. 

It  is  seldom  that  I  have  found  it  necessary  or  useful  to  apply  any 
bandages  directly  to  the  skin ;  but  in  certain  cases  of  compound  frac- 
tures where  dressings  have  been  applied  which  needed  support  and 
protection,  a  bandage  has  been  of  service.  The  roller,  unless  the 
patient  is  a  child,  whose  limb  can  be  easily  lifted  and  managed,  is 
always  objectionable;  but  the  many-tailed  bandage,  made  of  narrow 
strips  of  cloth,  laid  upon  each  other  as  we  have  already  described  in 
our  general  remarks  upon  bandages,  &c.,  is  much  to  be  preferred. 

Having  made  these  preparations,  we  proceed  to  flex  the  leg  to  a 
right  angle  with  the  thigh,  and,  by  the  hands,  make  extension  and 
counter-extension  as  much  as  the  patient  will  bear,  or  as  much  as 
may  be  necessary  to  restore  the  fragments  to  place.  If  the  fracture  is 
compound,  and  the  point  of  bone  protrudes  through  the  skin,  it  is 
often  difficult  to  replace  it.  That  is,  we  are  unable  to  overcome  the 
action  of  the   muscles  sufficiently  to  make  the  limb  of  its  natural 


464  FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 

length,  and  for  this  reason,  mainly,  we  are  unable  to  get  the  point  of 
bone  beneath  the  skin.  If  we  cannot  then  "set"  the  bone,  or  bring 
the  ends  into  apposition,  and  this  will  be  the  fact  pretty  often,  we  still 
have  no  apology  generally  for  leaving  the  bone^outside  of  the  skin. 
First  an  attempt  must  be  made  to  accomplish  this  reduction  by  pulling 
aside  the  skin  with  the  fingers,  or  with  a  blunt  hook.  This  simple 
procedure  has  often  succeeded  with  me  in  a  moment,  when  others 
have  been  trying  in  vain  to  accomplish  the  same  end  by  pulling  upon 
the  limb.  If  this  fails,  then  the  skin  should  be  cut  sufficiently  to  allow 
the  bone  to  retire,  or  if  the  point  is  sharp,  and  especially  if  it  is  strip- 
ped of  its  periosteum,  it  may  be  sawn  off.  Eesecting  thus  the  end  of 
an  oblique  fragment  does  not  generally  affect  in  any  degree  the  length 
of  the  limb,  or  interfere  with  a  prompt  and  perfect  cure,  but  on  the 
contrary  it  often  is  advantageous  in  every  point  of  view. 

Having  restored  the  fragments  to  their  places  as  well  as  we  may, 
the  limb  is  laid  carefully  on  its  outside  upon  the  long  wooden  splint. 
We  shall  now  find  it  necessary  generally  to  add  two  or  three  thin  pads, 
in  order  to  supply  vacancies  which  we  have  not  perfectly  provided 
for  in  the  preparation  of  the  splint.  Generally  we  shall  also  see  the 
necessity  of  placing  a  pretty  thick  pad  under  the  outer  margin  of  the 
foot  or  toes,  so  as  to  bring  the  great  toe  in  line  with  the  inner  edge  of 
the  patella,  and  spine  of  the  tibia.  The  other  side  splint  is  now  laid 
along  the  inner  or  tibial  side  of  the  limb  and  with  successive  turns  of 
a  roller,  or  with  a  number  of  narrow  and  separate  strips  of  cloth,  the 
whole  are  bound  together,  and  the  limb  is  left  to  repose  upon  its  outer 
side. 

The  patient  may,  if  necessary,  lie  upon  his  back,  but  it  is  better 
that  he  should  be  turned  a  little  toward  the  side  of  the  broken  limb. 
The  danger  of  twisting  the  fragments  upon  each  other  is  lessened  by 
lying  upon  the  same  side  with  the  broken  limb,  but  I  have  frequently 
permitted  patients  to  lie  upon  their  backs  and  found  no  such  result. 
If  the  long  under  splint  extends  a  little  way  upon  the  thigh  and  is 
well  fastened  to  the  thigh,  the  twist  cannot  very  well  occur. 

By  adopting  this  general  plan  of  treatment  we  avoid  all  chances  of 
gangrene  or  swelling  of  the  foot  from  excessive  ligation,  and  it  is  to 
these  accidents,  especially,  that  the  remarks  of  Dr.  Norris,  already 
quoted,  are  applicable.  The  large  size,  and  irregular  form,  of  the 
bones  of  the  leg,  the  small  amount  of  muscular  tissue  covering  them, 
especially  near  the  articulations,  the  severity  of  the  injuries  to  which 
they  are  liable,  with  their  remoteness  from  the  centre  of  circulation — 
these  circumstances,  altogether,  render  them  exceedingly  exposed  to 
injury  from  the  too  great  or  unequal  pressure  of  splints  or  of  bandages; 
and  it  has  often  occurred  to  myself,  as  it  has  to  Dr.  Norris,  to  find  the 
skin  vesicated,  or  even  ulcerated  and  sloughing,  when  the  patients  are 
first  admitted  to  the  hospital ;  a  condition  which,  in  nine  cases  out  of 
ten,  is  due  to  the  mal-adjustment  of  the  splints,  or  to  the  tightness  of 
the  bandages. 

If  bandages  are  used  under  the  splints,  and  next  to  the  skin,  they 
must  be  applied  very  moderately  tight,  and  loosened  or  cut  as  the 
swelling  augments ;  and  from  the  first  day  of  the  treatment  to  the  last, 


FRAGTUEES    OF    THE    TIBIA    AND    FIBULA.  465 

the  surgeon  must  be  careful  to  loosen  or  tighten  the  dressings  when  the 
swelling  increases  or  subsides,  just  as  the  prudent  boatman  trims  his 
sails  to  the  rising  and  falling  breeze. 

The  following  case,  which  has  been  communicated  to  me  by  Dr. 
Fuller,  of  Wyoming,  N.  Y.,  with  permission  to  make  such  use  of  it 
as  I  choose,  is  sufficiently  pertinent  for  the  instruction  of  others,  and 
deserves  a  public  record. 

A  man,  aet.  71,  fell  from  a  tree,  striking  upon  his  foot,  Aug.  27,  1855, 
producing  a  backward  dislocation  of  both  the  tibia  and  fibula  upon 
the  OS  calcis,  and  also  a  fracture  of  both  bones  of  the  leg  a  few  inches 
above  the  ankle. 

An  empiric  took  charge  of  this  unfortunate  man,  and  immediately 
applied  lateral  splints  and  a  firm  roller  from  the  toes  to  the  knee. 
Notwithstanding  the  remonstrances  and  prayers  of  the  patient  to  have 
the  bandage  loosened,  it  was  kept  on  until  the  ninth  da}^,  when  the 
doctor  cut  the  bandage  upon  the  top  of  the  foot,  and  it  was  found 
vesicated.  Ignorant,  however,  as  to  the  cause  of  this  vesication, 
and  of  the  danger  which  it  threatened,  he  omitted  to  loosen  the  re- 
mainder of  the  bandages,  and  the  limb  was  left  in  this  condition  until 
the  twenty-third  day,  when  Dr.  Fuller  being  called  and  having  re- 
moved all  the  dressings,  found  the  integuments  covering  the  whole 
foot  dead  and  dried  down  to  the  bones.  The  dislocations  had  not 
been  reduced.  Soon  after  this  the  limb  became  oedematous,  and  on 
the  twenty-seventh  of  October  the  leg  was  amputated  by  Dr.  Barrett, 
of  Le  Roy;  from  which  time  the  patient  recovered  rapidly. 

But  it  is  to  the  advantages  of  the  posture  recommended  by  Pott 
that  I  wash  especially  to  direct  attention.  The  position  hitherto  gene- 
rally preferred  by  surgeons  has  been  that  in  which  the  limb  rests  upon 
its  back,  either  in  a  box  or  upon  a  double  inclined  plane;  but  all  of 
the  five  examples  of  ulcers  upon  the  heel  which  I  have  seen  have  been 
after  treatment  in  this  position.  Indeed,  it  is  almost  impossible  for 
this  accident  to  happen  in  any  other  way,  and  it  has  therefore  never 
occurred  to  me  to  see  it  in  cases  treated  by  Pott's  method.  It  is  true 
that,  with  great  care,  such  a  result  might  generally  be  prevented  while 
the  leg  is  resting  upon  its  calf,  yet  experience  shows  that  it  is  by  no 
means  easy  to  avoid  it  always.  And  if,  in  our  anxiety  to  obviate  this 
evil,  we  place  pads  underneath  the  tendo  Achillis,  above  the  heel,  we 
incur  the  risk  of  pressing  the  fragments  forwards,  and  of  compelling 
them  to  unite  with  the  whole  lower  part  of  the  leg  inclined  backwards. 
I  have  mentioned  already  that  this  has  happened  in  cases  that  have 
subsequently  come  under  my  observation  no  less  than  seven  times, 
1  while  an  attempt  to  correct  this  fault  by  placing  the  support  under 
the  heel  has  either  produced  ulcers  of  the  heel,  or  driven  the  lower 
part  of  the  limb  in  the  opposite  direction. 

The  same  thing — that  is,  a  deviation  backwards  or  forwards — might 
happen  in  any  posture,  but  I  am  sure  it  is  much  less  liable  to  in  Pott's 
position  than  in  any  other. 

Then,  again,  a  twist  or  rotation  of  the  lower  fragment  is  more  liable 
to  take  place  when  the  toes  point  upwards,  and  the  limb  rests  upon  the 
calf  and  heel,  than  when  the  limb  reposes  upon  its  side.     In  the  one 
30 


4,6Q  FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 

case  it  is  resting  upon  a  narrow  surface,  with  the  whole  weight  of  the 
foot  disposing  it  to  either  eversion  or  inversion,  while  in  the  other  it 
lies  upon  a  broad  surface,  with  the  foot  entirely  at  rest,  and  demanding 
no  extraordinary  support.  ~~^ 

In  short,  Pott's  position  is  less  irksome  to  the  patient,  and  vastly  less 
troublesome  to  the  surgeon.  Ugly  and  crooked  limbs  are  sometimes 
inevitable,  and  they  are  often  the  consequences  of  unskilful  manage- 
ment or  of  inattention  on  the  part  of  the  surgeon;  but,  other  things 
being  equal,  the  best  legs  have,  in  my  experience,  come  out  of  Pott's 
position,  and  the  worst  out  of  the  double  inclined  plane  and  the  box. 

As  to  the  tendency  of  the  upper  fragment  to  rise  at  the  point 
of  fracture,  it  depends,  no  doubt,  upon  the  usual  direction  of  the 
fracture,  and  the  action  of  the  muscles  both  in  front  and  behind ;  so 
far  as  the  former  circumstance  is  the  cause — that  is,  the  direction  of 
the  line  of  fracture — no  position  is  sufficient  to  remedy  it,  and  in  rela- 
tion to  the  action  of  the  muscles,  the  indications  are  as  easily  and 
naturally  fulfilled  with-  the  limb  upon  its  side  as  upon  its  back.  Gene- 
rally the  leg  needs  to  be  flexed  upon  the  thigh ;  but  if  the  fracture  is 
high  up,  and  its  direction  is  obliquely  downwards  and  forwards,  it 
must  be  made  nearly  or  quite  straight,  so  as  to  overcome  the  action 
of  the  anterior  muscles  of  the  thigh,  acting,  through  the  ligamentum 
patellae,  upon  the  upper  fragment.  The  simple  rule  which  I  recom- 
mend and  adopt  is,  to  flex  or  extend  the  limb  more  or  less  until  it  is 
ascertained  in  what  position  the  apposition  of  the  fragments  is  most 
cortiplete. 

In  such  few  cases  as  demand  or  warrant  a  resort  to  extension  and 
counter-extension,  a  double  inclined  plane  furnishes  the  most  conve- 
nient mode  for  its  accomplishment;  but  it  is  only  occasionally  that,  in 
fractures  of  the  leg,  permanent  extension  and  counter-extension  can 
be  employed,  an  assertion  which,  however  much  it  may  excite  surprise, 
experience  will  prove  true.  If  the  fracture  is  near  the  middle  of  the 
leg,  quite  remote  from  the  points  upon  which  the  appliances  for  ex- 
tension, &c.,  are  to  be  made  fast,  and  the  inflammation  is  moderate, 
something  may  be  done  in  this  way ;  but  when  the  point  of  fracture 
approaches  the  ankle-joint,  as  it  actually  does  in  a  great  majority  of 
cases,  a  gaiter,  made  of  any  material  whatever,  if  it  has  sufiicient  firm- 
ness to  overcome  completely  the  action  of  the  muscles,  will  inevitably 
cause  congestion  and  swelling,  accompanied  sooner  or  later  with  great 
pain  and  with  ulcerations,  and  simply  because  the  extension  is  made 
directly  upon  parts  already  tender  and  inflamed  from  the  accident 
itself;  and  when  we  add  to  this  complete  and  violent  ligation  of  the 
limb  near  the  seat  of  fracture,  a  similar  ligation  of  the  limb  just  below 
the  knee,  for  the  purpose  of  making  counter-extension,  as  is  done  in 
what  is  known  among  American  surgeons  as  "Hutchinson's  splint"^ 
(Fig.  194),  we  are  prepared  to  understand  how  the  worst  consequences 
may  ensue.  I  have  once  seen,  when  this  abominable  apparatus  had 
been  used,  a  complete  ring  of  ulceration  below  the  knee,  and  another 
as  complete  around  the  foot  and  ankle.     The  limb  was  twice  girdled, 

'  Elements  of  Surgery,  by  John  Syng  Dorsey,  vol.  i.  p.  181.     Philadelphia,  1813. 

I 


FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 


467 


and  yet  the  surgeon  thought  he  was  performing  a  duty  for  the  omission 
of  which  he  would  scarcely  have  been  regarded  as  excusable. 

Fig.  194. 


James  Hutchinson's  splint  for  extension,  etc.,  in  Iractures  of  the  leg.     (From  Gibson.) 

Jarvis's  adjuster,  a  still  more  mischievous,  inasmuch  as  it  is  a  more 
powerful,  instrument,  operating  in  a  similar  manner,  has  been  pro- 
ductive of  like  consequences;  but  Jarvis's  adjuster  is  liable  to  the 
additional  objection  that  by  its  great  weight  it  drags  off"  the  limb, 
turning  the  toes  outwards,  an  objection  which  no  care  or  diligence  can 
generally  overcome. 

I  could  wish  that  neither  of  these  appliances  would  ever  again  be 
impressed  into  the  service  of  broken  legs. 

Neill,  of  Philadelphia,  Crandall,  of  New  York,  and  Daniels,  of 
Broome  Co.,  N.  Y.,  have  each  sought  to  overcome  some  of  the  diffi- 
culties in  the  way  of  making  extension  in  fractures  of  the  legs,  by 
substituting  adhesive  plaster  for  the  usual  extending  or  counter- 
extending  bands. 

Says  Dr.  Neill:  "For  simple  fractures  of  both  bones  of  the  leg,  at- 
tended with  shortening  and  deformity  not  easily  overcome,  the  limb 
should  be  placed  in  a  long  fracture-box  (Fig.  195),  with  sides  extend- 
ing as  high  as  the  middle  of  the  thigh,  and  a  pillow  should  be  used  for 
compresses. 

Fig.   195. 


John  Neill's  apparatus  for  fractures  of  the  leg,  requiring  extension  and  counter-extension. 

"The  counter-extension  is  made  by  strips  of  adhesive  plaster,  one 
inch  and  a  half  in  breadth,  secured  on  each  side  of  the  leg  below  the 
knee,  and  above  the  seat  of  fracture,  by  narrower  strips  of  plaster  ap- 
plied circularly.     The  end  of  the  counter-extending  strips  may  then 


468 


FEACTURES    OF    THE    TIBIA   AND    FIBULA. 


be  secured  to  lioles  in  the  upper  end  of  the  sides  of  the  fracture-box, 
by  which  the  line  of  the  counter -extension  is  rendered  nearly  parallel  with 
the  limb.  / 

"The  extension  is  also  to  be  made  by  adhesive  strips,  in  a  mode 
which  is  now  well  known  and  understood.  The  ends  of  the  extending 
bands  may  be  fastened  to  the  foot-board  of  the  box."^ 

Dr.  Neill  further  remarks :  "  In  compound  fractures  of  the  leg,  short- 
ening and  deformity  are  often  difficult  to  overcom.e,  as  is  well  known 
to  experienced  surgeons.  In  such  cases  we  may  wish  to  dress  the 
wounded  soft  parts,  and,  at  the  same  time,  maintain  a  certain  amount 
of  extension  and  counter-extension. 

"This  can  be  readily  accomplished  by  having  the  sides  of  the  frac- 
ture-box (Fig.  196)  sawed  in  two  parts  at  the  knee,  so  that  the  sides 
of  the  box  above  the  knee,  from  the  upper  ends  of  which  the  counter- 
extension  is  made,  need  not  be  disturbed  during  the  dressing,  while 
that  portion  of  the  side  of  the  box,  corresponding  to  the  leg,  may  be 
opened  at  pleasure,  without  diminishing  the  tension  of  the  extending 
or  counter-extending  bands." 

Fig.  196. 


Join  Neill's  apparatus  for  compound  fractures  of  the  leg. 

The  following  wood-cuts  (Pigs.  197,  198,  199)  are  intended  to  illus- 
trate the  apparatus  invented  by  R.  0.  Crandall,  for  the  purpose  of 
making  permanent  extension.  The  extension  is  represented  as  being 
made  by  a  gaiter,  but  Dr.  Crandall  leaves  it  to  the  choice  of  the  sur- 
geon whether  he  shall  employ  the  gaiter  or  adhesive  straps.^ 


Section  of  Crandall's  apparatus,  applied  to  the  limb;  showing  adhesive  plaster  counter-extending 
band,  gaiter  for  extension,  &c. 


'  Philadelphia  Med.  Exam.,  vol.  xi.  p.  580,  1855. 

2  Crandall,  Phil.  Med.  Journ.,  vol.  iv.  p.  193,  Jan.  1856  ;  also  Transac.  of  Med.  Assoc, 
of  Southern  and  Central  New  York,  1855,  pp.  81,82. 


FRACTURES    OF    THE    TIBIA    AND    FIBULA.  469 

Fig.  198. 


Posterior  view  of  the  lower  portion  of  Crandall's  apparatus. 
Fig.  199. 


Crandall's  apparatus  complete.     The  counter-extending  straps  are  passed  over  a  block  of  wood  sup- 
ported above  the  knee,  to  prevent  their  pressure  upon  the  sides  of  the  knee. 

Without  intending  to  deny  to  these  contrivances  much  ingenuity 
and  considerable  practical  value,  I  am  far  from  conceding  that  they 
will  be  found  capable  of  overcoming  altogether  the  action  of  the  mus- 
cles where  the  ends  of  the  fragments  do  not  support  each  other.  Their 
mode  of  action  is  such  that  they  can  scarcely  do  more  than  to  steady 
the  limb,  and  if  they  operate  upon  the  fragments  at  all  in  the  direction 
of  their  axes,  it  must  be  only  in  the  most  inconsiderable  degree.  The 
adhesive  plasters  are  substituted  for  the  circular  knee  bands  and  the 
gaiters  with  a  view  to  avoid  the  ligation ;  but  in  order  to  do  this  they 
must  not  encircle  the  limb,  but  only  be  laid  parallel  to  its  long  axis. 
The  leg  of  an  adult  or  that  portion  to  which  the  adhesive  plasters 
can  be  applied,  supposing  the  fracture  to  be  exactly  at  the  centre, 
may  be  sixteen  inches,  that  is,  eight  inches  for  extension  and  eight  for 
counter-extension ;  but  when  we  employ  the  same  means  for  extension 
in  fractures  of  the  thigh,  we  find  it  necessary  to  apply  the  straps 
over  the  whole  of  these  sixteen  inches,  the  entire  length  of  the  leg,  or 
they  will  not  hold.  It  will  be  apparent  also  that  we  cannot  use  even 
the  eight  inches  which  we  have,  for  the  purposes  of  argument,  allowed 
these  gentlemen  in  fractures  of  the  leg.  There  must  be  at  least  a 
space  of  eight  inches  between  the  ends  of  the  two  opposing  straps  in 
order  that  they  may  operate  at  all  upon  the  fragments;  indeed  I  do 
not  believe  that  even  then  their  influence  would  reach  beyond  the  skin 
to  which  they  were  directly  applied ;  but  if  a  space  of  eight  inches  is 
left,  only  four  remain  for  the  straps  at  either  end ;  and  this  is  an  amount 
of  surface  wholly  insufficient  for  our  purpose.  What  then  shall  we 
do  when  the  fracture  is  near  one  of  the  extremities  of  the  bone? 
These  gentlemen  seem  to  have  forgotten,  moreover,  that  the  whole  leg 
is  tender  and  that  the  skin  easily  vesicates.  In  short,  they  have  not 
seen  the  many  points  of  diiference  between  the  application  of  these 
means  in  fractures  of  the  thigh  and  leg,  and  which,  while  they  allow 


470 


FEACTUEES    OF    THE    TIBIA    AND    FIBULA. 


Fig.  200. 


US  to  accomplish  all  that  we  could  desire  with  the  one,  are  of  little  or 
no  use  in  the  other.  We  shall  then  always  come  to  the  same  conclu- 
sion ;  whatever  means  we  may  employ  ^o  make  permanent  extension 
in  fractures  of  the  leg,  we  must  either  fail  entirely  or  incur  the  hazards 
incident  to  complete  and  firm  ligation  of  the  limb;  and  if  the  prefer- 
ence is  given  to  any  form  of  apparatus  to  accomplish  these  ends,  it 
must  be  to  some  form  of  the  double  inclined  plane,  by  which  we  may 
at  least  avoid  ligation  in  the  upper  part  of  the  limb,  the  counter- 
extension  being  made  against  the  under  surface  of  the  thigh  while  it 
is  resting  upon  the  thigh  piece;  or  to  one  of  the  long  straight  thigh 
splints  which  will  enable  us  to  make  the  counter-extension  from  the 
thigh  and  perineum. 

The  paste,  starch,  or  dextrine  bandage  (Fig.  200),  I  have  used  in 
a  few  cases  of  simple  fracture  of  the  leg  within  a  day  or  two  after 

the  accident,  but  not  unless  I  felt 
certain  from  the  nature  of  the  injury 
that  no  swelling  was  to  occur.  It  is 
only  in  those  fractures  in  which  the 
bones  do  not  become  displaced,  or 
only  very  slightly,  that  I  would  re- 
commend its  employment  at  a  period 
so  early. 

But  as  soon  as  the  fragments  have 
united,  in  almost  any  form  of  frac- 
ture of  the  leg,  it  will  not  be  impro- 
per to  put  on  the  paste  bandage  and 
allow  the  patient  to  go  about  care- 
fully upon  crutches ;  or  if,  indeed, 
the  fragments  have  not  united,  but 
the  swelling  has  completely  sub- 
sided and  the  wounds  healed,  it  can- 
not be  regarded  as  unsafe  to  adopt 
this  practice.  The  young  surgeon 
cannot,  however,  be  too  much  im- 
pressed with  the  danger  of  this  mode 
of  treatment,  as  a  universal  or  gene- 
ral plan,  employed  without  discrimi- 
nation. Its  most  devoted  advocates, 
Suetin,  Velpeau,  Gamgee,  and  others,  will  not  deny  the  necessity  of 
caution  in  its  use ;  and  the  numerous  accounts  of  crooked  limbs,  ulcera- 
tions, and  even  of  gangrene  which  have  been  attributed  fairly,  I  think, 
to  one  or  another  of  the  forms  of  the  immovable  dressing,  ought  to  be 
sufficient  to  place  us  fully  upon  our  guard.-' 

The  majority  of  such  cases  as  in  my  judgment  may  be  safely 
intrusted  to  a  paste  bandage,  will  also  do  well  enough  in  almost  any 
form  of  dressing;  and  not  a  few  of  the  examples  of  simple  fracture  of 
the  leg  without  much  if  any  displacement,  which  have  come  under 


"Immovable"  apparatus:  applied  to  the  leg 
(From  Fergusson.) 


'  Accidents  resulting  from  the  use  of  the  immovable  apparatus.     Amer.  Journ.  Med. 
Sci.,  vol.  XXV.  p.  460,  Feb.  1840 ;  from  Gazette  des  Hopitaux. 


FEACTURES    OF    THE    TIBIA   AND    FIBULA. 


471 


my  notice,  I  have  treated  by  simply  inclosing  the  leg  neatly  in  a 
pillow,  tied  against  the  limb  with  tapes,  only  that  I  have  taken  care 
that  the  pillow  shall  be  so  fastened  around  the  foot  and  leg  as  to 
keep  the  limb  steady.  At  other  times  I  have  laid  outside  of  the  pillow 
thus  arranged,  two  broad  side  splints,  and  bound  these  against  the 
limb,  with  the  pillow  interposed  ;  or  I  have  in  the  summer  used  splints 
made  of  rolls  of  straw  inclosed  in  pieces  of  cloth — "  straw  junks,"  In 
all  these  cases  I  have  laid  the  leg  upon  its  back,  and  I  cannot  say  but 
that  the  limbs  have  done  well. 

If  a  double  inclined  plane  is  used,  I  prefer  either  a  plain  apparatus, 
such  as  we  have  already  described  as  in  use  for  fractures  of  the  thigh, 
constructed  of  boards,  joined  together  by  hinges  opposite  the  knee, 
and  with  an  upright  foot-board,  upon  which  a  carefully  arranged  and 
thick  cushion  has  been  placed,  or  the  more  elegant  double  inclined 
plane  of  Listen  (Fig.  201)  or  of  Welch  (Fig.  202). 

Fig.  201. 


Listen's  double  inclined  plane  ;  applied  to  the  leg  in  a  case  of  compound  fracture.     (From  Miller.) 

If  Welch's  splint  is  preferred,  a  piece  of  narrow  board  should  be 
placed  transversely  under  the  heel  of  the  apparatus,  and  made  fast,  as 
may  be  seen  in  Liston's  splint,  so  as  to  prevent  its  tendency  to  fall  over 
to  one  side  or  the  other. 

Fig.  202. 


B.  Welch's  jointed  apparatus  for  fractures  of  the  leg. 

The  apparatus  may  be  flexed  or  extended,  and  fixed  in  the  position 
required,  by  the  hinges.  This  is  done  by  means  of  pinion-like  teeth  at 
the  circumference  of  the  hinges,  which  are  held  in  contact  by  screws 
forming  the  pivots  of  the  joints.  It  is  fitted  to  limbs  difiering  in  length 
by  sliding  joints  at  the  sides  of  the  limb,  and  in  the  splint  which  supports 


472 


FEACTURES    OF    THE    TIBIA    AND    FIBULA. 


the  under  side  of  the  limb.     The  depth  is  increased  or  diminished  by 
turning  a  screw  at  the  bottom  of  the  foot-piece, 

Welch's  side  splints,  also  (Fig.  203),  Made  of  veneered  gutta  percha, 
may  be  used  in  connection  with  his  double  inclined  plane,  and  are 
especially  useful  in  fractures  occurring  near  the  ankle-joint. 

Fig.  203. 


B.  Welch's  flexible  side  splints.  . 

These  side  splints  may  be  confined  to  the  limb  by  bandages  or 
straps,  and  indeed  to  bandages  I  always  give  the  preference. 

In  using  Welch's  or  Liston's  apparatus,  it  must  not  be  inferred  that 
the  knee  is  always  to  be  bent.  These  splints  are  designed  to  be  used 
occasionally  as  single  planes  or  as  straight  splints  ;  and  there  will  be 
found  many  cases  of  fractures  of  the  legs  in  which  the  straight  posi- 
tion, will  be  most  suitable:  this  is  especially  true  of  such  fractures  as, 
occurring  just  below  the  knee-joint,  have  the  line  of  fracture  directed 
obliquely  downwards  and  forwards.  But  there  are  many  compound 
fractures  which  demand  the  same  extended  position  ;  and  in  nearly 
all  cases  where  this  form  of  apparatus  is  used  as  a  double  inclined 
plane,  the  lower  end  of  the  splint  should  be  elevated  so  that  the  heel 
shall  not  be  much  below  the  level  of  the  knee. 

Bauer's  wire  splints,  used  also  for  side  splints  (Fig.  204),  when  they 
are  formed  to  fit  the  limb  accurately,  possess  some  advantages  which 

Fig.  204. 


Louis  Bauer's  wire  splints  for  the  leg.' 
'  Bauer,  Buffalo  Medical  Journal,  April,  1857,  vol.  xii. 


FKACTURES    OF   THE    TIBIA   AND    FIBULA. 


473 


must  recommend  them  to  the  attention  of  surgeons ;  but  neither  these 
splints  nor  any  others,  however  accurately  fitted,  ought  to  be  applied 
^irectly  to  the  naked  skin.  They  require  always  the  interposition  of 
t  well-padded  lining. 

Boxes  are  rarely  useful  except  in  certain  compound  fractures.  They 
aie  heavy  and  awkward  machines,  which  prevent  the  patient  from 
moving  readily  in  bed ;  or  which  being  fixed,  if  he  does  move,  allow 
the  upper  fragment  only  to  descend,  or  to  move  upon  the  lower  as  a 
fixed  point.  If  used  at  all,  they  ought  generally  to  be  suspended  (Fig. 
205j,  or  made  to  move  on  a  suspended  railway  (Fig.  206).  But,  how- 
ever they  are  arranged,  the  limb  is  a  great  part  of  the  time  concealed 
from  sight,  and  the  surgeon  is  prevented  from  making  use  of  such 
means  to  rectify  deviations  in  the  line  of  the  bone,  as  he  would  pro- 
bably have  otherwise  employed. 

Fig.  205. 


Swing  box  or  "cradle."    (From  Skey.) 


The  swing  invented  by  James  Salter,  of  London  (Fig.  206),  is  con- 
structed so  as  to  allow  not  only  a  lateral  motion,  but  also  a  more  com- 


Salter's  cradle.     (From  Fergusson.) 


474 


FEACTURES    OF    THE    TIBIA    AND    FIBULA. 


Fig.  207. 


plete  motion  in  the  direction  of  the  axis  of  the  limb,  by  which  the  dan- 
ger of  pushing  the  fragments  upon  eaclh  other  is  obviated.  This  is 
accomplished  by  the  rolling  of  two  pulley-wheels  upon  a  horizontal 
bar.  The  case  in  which  the  leg  rests  may  be  made  of  metal  or  of  wood, 
and  the  frame  of  iron  for  the  sake  of  lightness  and  strength. 

These  boxes  are  sometimes  filled  with  bran,  the  bran  being  closely 
packed  upon  all  sides  so  as  to  support  the  limb  uniformly  and  genoly. 
This  method  of  treating  compound  fractures  of  the  leg  was  first  sug- 
gested by  J.  Ehea  Barton,  of  Pnila- 
delphia,^  and  has  been  much  ussd  in 
the  Pennsylvania  Hospital.  It  pos- 
sesses the  advantage  of  affording  a 
perfect  protection  against  flies  in  the 
summer  season,  and  of  absorbing  the 
matter  as  it  escapes.  Whenever  any 
portion  of  it  becomes  soiled  by  blood 
or  pus  it  may  be  dipped  out  with  a 
spoon,  and  its  place  supplied  with 
fresh  bran.  The  support  which  it 
gives  to  the  limb  is  also  uniform 
without  being  at  any  time  excessive,  and  Dr.  Coates  states  that  the 
escape  of  blood  in  rapid  hemorrhages  has  been  known  to  increase  the 
bulk  of  the  bran  sufficiently  to  arrest  the  bleeding  by  its  accumulated 
pressure. 

Malgaigne,  who  declares  that  the  whole  world  knows  how  impos- 
sible it  is,  in  an  immense  majority  of  cases,  to  overcome  the  projection 
of  the  superior  fragment  when  the  limb  is  placed  in  the  extended 
position  (over  a  double  inclined  plane),  and  who  affirms  that  neither 
Pott's  position,  nor  Dupuytren's  modification  of  it,  will  do  much,  if 
any  better,  nor,  indeed,  that  Laugier's  plan  of  cutting  the  tendo 
Achillis  possesses  in  this  respect  any  real  advantage,  concludes  at  last 
to  resort  to  a  new  and  really  ingenious  method,  the  value  of  which, 
also,  he  claims  to  have  already  fully  demonstrated.  His  apparatus 
(Fig.  208)  consists  simply  of  a  steel  band  of  sufficient  size  to  encircle 

Fig.  208. 


Fracture  bos,  with  movable  sides. 


Malgaigne's  apparatus  for  oblique  fractures  of  the  leg.     (From  Malgaigne.) 

three-fourths  of  the  limb,  at  the  two  extremities  of  which  are  two  hori- 
zontal mortises  through  which  a  band  is  passed,  and  which  may  be 
buckled  upon  itself  behind.     The  centre  of  the  metallic  arch,  in  front, 


'  Barton,  Amer.  Journ.  of  Med.  Sci.,  vol.  xvi.  p.  31,  and  vol.  xix.  p.  515. 


FRACTUEES    OF    THE    TIBIA    AND    FIBULA. 


475 


is  penetrated  with  a  firm,  metallic  screw,  terminating  in  a  very  sharp 
point,  and  which  is  moved  by  a  flat  thumb-piece. 

The  limb  being  laid  over  a  double  inclined  plane,  and  the  pads 
being  carefully  adjusted,  as  we  have  already  directed  when  speaking 
of  other  forms  of  apparatus,  and  the  limb  properly  extended,  the  ap- 
paratus of  Malgaigne  is  placed  over  the  limb,  with  the  sharp  point  of 
the  screw  resting  upon  the  upper  fragment,  a  few  lines  above  the 
point  of  fracture ;  and  at  the  same  moment  that  this  point  is  pressed 
firmly  down  to  the  bone,  the  fragments  being  held  together  by  an 
assistant,  the  strap  is  buckled  as  tightly  as  possible  under  the  splint. 
A  few  turns  of  the  screw  will  now  make  its  point  penetrate  more 
deeply  into  the  bone,  and  insure  the  most  complete  apposition  of  the 
broken  extremities.  "  This  is  accomplished,"  says  Malgaigne,  "  with 
very  little  pain  to  the  patient ;"  and,  as  will  be  seen  (Fig.  209),  the 
steel  arch  effectually  prevents  any  ligation  of  the  limb. 

Fig.  209. 


Malgaigne's  apparatus  applied.     (From  Malgaigne.) 

Although  I  have  had  for  some  time  this  instrument  in  my  posses- 
sion, I  confess  that  I  have  been  reluctant  to  make  use  of  it  in  any 
case  which  has  presented  itself  to  me.  My  friend,  Dr.  March,  of 
Albany,  has,  however,  employed  it  in  his  practice,  and  he  expresses 
himself  as  much  pleased  with  its  operation. 

The  authority  of  either  of  these  distinguished  gentlemen  is,  in  my 
judgment,  a  sufficient  guarantee  of  its  excellence,  and  I  think  I  shall 
only  wait  for  another  favorable  opportunity  to  give  it  a  fair  trial. 

In  some  cases  of  extreme  deformity  of  the  legs  consequent  upon 
badly  united  fractures,  resection  of  the  bones  has  been  practised  with 
more  or  less  success. 

The  first  case  of  which  I  have  seen  any  mention  made  where  the 
bones  were  actually  resected,  is  reported  by  Charles  Parry,  of  Indiana- 
polis, Ind.  A  young  man,  aet.  15,  having  broken  his  leg  near  its 
middle,  the  fragments  united,  from  some  cause,  nearly  at  right  angles 
with  each  other.  Some  years  afterwards,  on  the  15th  day  of  January, 
1838,  Dr.  Parry  operated,  by  removing  a  wedge-shaped  portion  from 
both  the  tibia  and  fibula.    The  recovery  was  tedious,  but  satisfactory.' 

1  Parry,  Amer.  Journ.  Med.  ^ci.,  Aug.  1839,  p.  334. 


476  FRACTUEES    OF    THE    TIBIA    AND    FIBULA. 

Mr.  Key,  of  London,  made  an  operation  of  this  kind  upon  a  gentle- 
man who  had  suffered  a  fracture  of  thelright  tibia  from  a  musket  ball. 
The  limb  was  nearly  useless,  since  he  could  only  bring  his  toes  to 
the  ground.  Mr.  Key  operated  in  Oct.  1838,  and  when  the  report  of 
the  case  was  made  five  months  subsequently,  the  patient  was  doing 
well' 

In  Sept.,  1840,  Dr.  Miitter,  of  Philadelphia,  made  a  similar  operation 
upon  a  patient  whose  leg  was  shortened  three  inches  and  a  half  and 
very  much  deformed,  by  which  operation,  when  the  recovery  was 
complete,  the  shortening  was  considerably  reduced.^ 

Cases  may  occur  which  will  justify  a  resort  to  these  extreme  mea- 
sures, or  in  which  they  may  be  preferred  to  amputation ;  but  an 
examination  of  the  several  examples  reported  will  show  that  these 
operations  are  not  unattended  with  danger  to  the  life  of  the  patient ; 
indeed,  in  this  respect,  amputation  has  greatly  the  advantage.  If, 
moreover,  the  surgeon  expects  by  this  method  to  lengthen  a  limb, 
where  it  is  merely  overlapped  and  shortened,  he  is  I  am  certain  destined 
to  disappointment,  at  least  in  all  cases  where  sufficient  time  has  elapsed 
for  the  bones  to  have  become  firmly  united.  I  have  never  myself 
refractured  a  bone,  but  I  have  several  times  met  with  cases  of  old 
fractures  newly  broken,  and  I  have  constantly  observed  that  I  could 
never  extend  the  limb  one  line  more  than  it  was  before  the  last  frac- 
ture. The  muscles  had  contracted  to  that  point,  and  their  contraction 
would  not  be  overcome.  In  the  case  reported  by  Mutter,  he  believed 
that  he  stretched  the  muscles  two  inches.  With  all  deference  for  the 
skill  and  honesty  of  this  gentleman,  I  think  that  he  was  mistaken. 

If,  however,  the  object  of  the  operation  is  to  straighten  the  limb, 
then  no  doubt  it  may  be  sometimes  accomplished ;  and  in  some  degree 
also  by  the  straightening  of  the  limb,  the  shortening  may  be  overcome; 
but  in  our  opinion,  such  procedures  ought  to  be  reserved  for  extra- 
ordinary circumstances. 

An  instructive  case  of  refracture  is  reported  by  Dr.  Horner,  of 
Philadelphia,  in  the  Medical  Exa7nmer.  The  limb  had  been  broken 
eight  weeks  and  was  quite  crooked,  but  was  not  very  firmly  united, 
and  Dr.  Horner  having  refractured  it,  was  able  at  once  to  restore  it  to 
a  nearly  straight  line.^ 

1  Key,  Amer.  Journ.  Med.  Sci.,  Aug.  1839,  p.  339,  from  Guy's  Hospital  Reports, 
April,  1839. 

2  Mutter,  Amer.  Journ.  Med.  Sci.,  April,  1842,  p.  359.  Three  similar  cases  may  also 
be  found  in  the  Oct.  No.  for  1841,  and  the  April  No.  for  1842  of  the  same  journal,  in 
which  the  operations  were  made  by  Portal,  of  Palermo.  Malgaigne  mentions  two  other 
examples. 

3  Horner,  New  York  Journ.  Med.,  May,  1851,  p.  432. 


FEACTUEES    OF    THE    TAESAL    BONES.  477 


CHAPTER    XXXIII. 

FEACTUEES  OF  THE  TAESAL  BONES. 

Causes. — The  astragalus  is  generally  broken  by  a  fall  from  a  height, 
the  patient  having  struck  upon  tbe  bottom  of  the  foot.  Monahan  in 
an  analysis  of  ten  cases,  found  it  had  been  broken  by  a  fall  upon  the 
foot  nine  times,*  and  only  once  by  a  crushing  accident. 

The  calcaneum  is  also  occasionally  broken  by  violent  lateral  pressure 
but  much  more  often  by  a  fall  upon  the  foot,  or  rather  upon  the  heel. 
In  some  instances  both  heel  bones  have  been  broken  at  the  same  mo- 
ment ;  but  Malgaigne  has  collected  eight  cases  of  fracture  of  this  bone 
by  muscular  action,  as  in  jumping  upon  the  toes;  the  posterior  por- 
tion of  the  bone  being  thus  violently  acted  upon  by  the  tendo  Achillis. 
South,  in  his  notes  to  Chelius,  has  mentioned  two  other  cases,  one  of 
which  was  seen  by  Lawrence,  and  has  been  reported  in  the  second 
volume  of  the  Lancet.  This  person  had  received  the  injury  by  jump- 
ing off'  a  stage  coach.  The  fragment  was  found  to  be  drawn  upwards 
slightly,  but  not  so  far  as  to  prevent  crepitus  when  the  muscles  on  the 
back  of  the  leg  were  relaxed.  The  other  example  mentioned  by  South, 
is  a  cabinet  specimen  contained  in  the  museum  of  St.  Bartholomew's 
Hospital.  The  fracture  had  taken  place  just  below  the  attachment  of 
the  tendo  Achillis,  but  the  upper  fragment  was  not  displaced.^  Mr. 
Cooper  mentions  two  other  cases,  both  produced  by  violent  efforts  on 
the  part  of  the  patients  to  sustain  themselves  when  falling.  In  one 
of  these  the  fragment  was  immediately  drawn  up  three  inches.' 

The  other  bones  of  the  tarsus  are  generally  broken  by  crushing 
accidents,  such  as  the  fall  of  heavy  weights  upon  them,  by  the  passage 
of  loaded  vehicles,  &c. 

Pathology. — The  astragalus  often,  indeed  generally,  escapes  without 
injury  in  those  crushing  accidents  which  break  many  or  most  of  the 
■'other  bones  of  the  foot,  and,  as  we  have  seen,  it  is  seldom  broken 
except  when  the  patient  has  fallen  upon  the  bottom  of  his  foot ;  but 
at  the  same  moment,  the  foot  being  turned  forcibly  out  or  in,  a  dislo- 
cation of  the  tibia  takes  place,  and  the  fibula  is  broken.  In  nine  of 
the  cases  collected  by  Monahan,  one  or  the  other  of  these  forms  of 
dislocation  had  occurred,  in  eight  of  which  the  dislocation  was  com- 
*  pound.  The  direction  of  the  fracture  is  found  to  vary  greatly ;  thus, 
it  has  been  found  broken  in  its  length,  antero-posteriorly,  in  its  breadth 
or  transversely,  and  in  one  instance  it  has  been  divided  nearly  hori- 

'  Fracture  of  the  astragalus,  wifh  an  analysis  of  the  recorded  cases  of  this  injury. 
An  inaugural  thesis,  presented  to  the  Faculty  of  the  Buffalo  Med.  Col.,  March,  1858, 
by  Bernard  Monahan,  M.  D. 

*  South,  Notes  to  Chelius's  Surgery,  vol.  i.  p.  639,  Amer.  ed. 

'  B.  Cooper's  ed.  of  Sir  Astley,  Amer.  ed.,  p.  311. 


478  FEACTURES    OF    THE    TARSAL    BONES. 

zontally,  so  as  to  separate  the  upper  face  completely  from  the  lower. 
Sometimes  it  suffers  a  species  of  impaction,  the  fragments  being  actu- 
ally driven  into  each  other ;  at  other  times,  as  in  one  case  related  by 
Amesbury,  the  bone  may  be  split  without  the  occurrence  of  any  dis- 
placement. 

The  calcaneum  also  maybe  broken  in  any  direction,  and  it  is  equally 
with  the  astragalus  liable  to  impaction,  by  which  its  vertical  diameter^ 
is  sensibly  diminished,  while  its  transverse  diameter  is  increased.     Ifj 
the  fracture  is  a  consequence  of  muscular  action,  the  line  of  fracture  is| 
always  posterior  to  the  astragalus,  and  in  some  cases  only  that  portionj 
is  broken  off  to  which  the  tendo  Achillis  has  its  attachment.     It  may 
be  broken  also  vertically,  directly  underneath  the  astragalus,  in  which 
case  the  lateral  and  interosseous  ligaments  will  prevent  anything  more 
than  a  slight  displacement  of  the  posterior  fragment.     When  the  frac- 
ture takes  place  posterior  to  the  lateral  ligaments,  the  detached  frag- 
ment is  liable  to  be  drawn  very  far  from  the  body  of  the  bone,  even  to 
the  extent  of  four  or  five  inches,  and  possibly  further  when  the  leg  is 
extended  upon  the  thigh  and  the  foot  flexed  upon  the  leg.     Constance 
relates  a  case  in  which  the  tuberosity,  having  been  broken  off  by  a 
direct  blow,  was  drawn  up  five  inches.' 

Fractures  of  the  calcaneum  produced  by  contraction  of  the  sural 
muscles  are  generally  simple,  but  those  which  result  from  a  crushing 
of  the  bone  are  more  often  compound.  The  same  remark  is  applicable 
also  to  the  other  bones  of  the  tarsus,  the  fractures  of  which,  beiug 
only  produced  by  direct  blows,  are  generally  complicated  with  exter- 
nal wounds. 

Symptoms. — All  fractures  of  the  bones  of  the  tarsus  demand  especial 
care  in  their  diagnosis,  since  only  a  few  of  the  usual  signs  of  fracture 
are  in  a  majority  of  the  cases  presented.  The  explanation  of  this 
fact  will  be  found  in  the  number,  size,  and  strength  of  the  bones _  o! 
the  tarsus,  and  in  their  close  and  firm  union  by  ligaments,  by  which 
they  give  to  each  other  a  mutual  support,  so  that  the  fracture  of  s 
single  bone  does  not  necessarily  or  usually  result  in  displacement  oi 
deformity,  and  even  crepitus  is  with  difiiculty  detected ;  and  when  we 
consider,  moreover,  that  the  fracture  is  generally  produced  by  great 
violence,  directly  applied,  in  consequence  of  which  the  foot  in  mosl 
cases  becomes  rapidly  and  enormously  swollen,  we  shall  understanc 
the  true  nature  of  the  difficulties  which  are  usually  presented  in  the 
way  of  an  accurate  diagnosis. 

Of  all  the  usual  signs  of  fracture,  crepitus  alone  is  pretty  generall): 
present,  but  even  this  often  fails  to  tell  us  which  bone  is  broken,  anc 
still  more  often  does  it  fail  to  inform  us  as  to  the  direction  and  exten 
of  the  bony  lesions. 

If  the  whole  or  a  portion  of  the  tuberosity  of  the  calcaneum  is  sepa 
rated  by  the  action  of  the  muscles,  and  the  fragment  is  drawn  upwards 
it  may  be  discovered  in  its  new  position,  and  the  heel  will  be  flattenec 
or  shortened,  but  no  crepitus  can  be  felt  unless  the  fragments  are  agaii 
brought  into  contact. 


'  Constance,  Amer.  Journ.  Med.  Sci.,  vol.  v.  p.  222,  Nov.  1829,  from  the  Midlau( 
Med.  and  Surg.  Reporter. 


I 


FEACTUEES    OF    THE    TAESAL    BONES.  479 

Treatment. — Not  any  of  the  fractures  of  the  tarsal  bones  in  them- 
selves demand  the  use  of  splints,  and  it  is  only  when  complicated  with 
a  dislocation  of  the  ankle  and  fracture  of  the  fibula  that  it  is  proper 
to  employ  apparatus  of  this  sort ;  certainly  the  exceptions  to  this  rule 
must  be  very  rare;  so  that  our  practice  in  these  cases  will  be  confined 
chiefly  to  the  prevention  and  reduction  of  inflammation.  The  limb 
must  be  placed  in  the  most  easy  position,  and  cool  water  lotions  assidu- 
ously applied.  This  will  be  the  sum  of  the  treatment  demanded  during 
the  first  few  days  after  the  receipt  of  the  injury  in  probably  all  cases 
of  simple  fracture,  and  in  many  cases  of  compound  fracture. 

If  single  bones,  or  fragments  of  single  bones,  are  displaced  to  any 
considerable  extent,  and  there  is  an  external  wound  communicating 
with  the  fracture,  I  have  no  doubt  it  would  be  best  in  all  cases  to  re- 
move at  once  by  dissection  the  projecting  bone,  even  although  it  were 
possible,  or  perhaps  easy,  to  force  it  back  again  to  its  place.  The  same 
rule  I  would  apply  to  examples  of  fracture  uncomplicated  with  any 
external  wound,  if  the  fragments  were  very  much  displaced,  and  could 
not  by  the  application  of  moderate  force  be  replaced,  since  the  bone 
left  to  project  would  prevent  the  patient  from  ever  wearing  a  boot 
with  comfort,  and  would  entail  as  much  weakness  upon  the  limb  as 
.would  be  likely  to  follow  from  its  complete  separation.  But  such 
cases  as  I  have  last  supposed  are  exceedingly  rare ;  indeed,  I  have 
never  met  with  a  simple  fracture  of  a  tarsal  bone  accompanied  with 
displacement, 

Norris  has,  however,  reported  a  case  of  fracture  of  the  astragalus 
accompanied  with  displacement  of  about  one-half  of  the  bone,  but 
without  any  lesion  of  the  soft  parts.  This  was  in  the  person  of  a  man 
set,  30,  who  was  admitted  into  the  Pennsylvania  Hospital  on  the  26th 
of  Sept.  1831,  "An  hour  previous  to  admission,  while  descending  a 
ladder,  he  slipped  and  fell  in  such  a  manner  as  to  throw  the  entire 
weight  of  his  body  upon  the  outer  part  of  his  left  foot.  Upon  exami- 
nation, the  foot  was  found  to  bfe  turned  inwards  and  nearly  immovable. 
A  slight  depression  existed  immediately  below  the  lower  end  of  the 
tibia,  and  there  was  a  considerable  hard  and  rounded  projection  on  the 
outer  part  of  the  foot,  a  little  below  and  in  front  of  the  extremity  of 
the  fibula.  The  skin  covering  this  projection  was  reddened,  but  not 
excoriated.     There  was  no  fracture  of  either  bones  of  the  leg," 

These  appearances  led  Drs,  Norris  and  Barton,  under  whose  care 
the  patient  was  placed,  to  regard  the  accident  as  a  simple  luxation  of 
the  astragalus  forwards  and  outwards ;  and  a  short  time  after  admis- 
sion efforts  were  made  to  reduce  it,  "  This  was  done  after  relaxing  in 
as  great  a  degree  as  possible,  the  muscles  of  the  leg,  by  fixing  the  knee 
and  having  assistants  to  keep  up  extension,  by  seizing  the  heel  and 
front  part  of  the  foot ;  at  the  same  time  the  bone  being  pushed  inwards 
and  toward  the  joint  by  the  surgeon.  These  efforts  were  continued 
for  a  considerable  time,  but  had  no  effect  in  changing  the  position  of 
the  bone, 

"  Six  hours  afterwards,  Drs,  Huston  and  Harris  saw  the  patient  in 
consultation,  when  efforts  were  again  made  at  reduction,  which  not 


480  FRACTURES  OF  THE  TARSAL  BONES. 

proving  more  effectual  than  in  the  first,trial,  the  excision  of  the  bone 
was  determined  on.  ' 

"  The  patient  being  properly  placed,  an  incision  was  made  through 
the  integuments,  parallel  with  the  course  of  the  tendons,  commencing 
a  short  distance  above  the  projection  on  the  foot,  and  extending  down 
far  enough  to  expose  fairly  the  astragalus  and  its  torn  ligaments. 
The  bone  was  then  seized  with  forceps  and  easily  removed  after  the  di- 
vision of  a  few  ligamentous  fibres,  that  continued  to  connect  it  to  the 
adjoining  parts. 

"  Very  little  hemorrhage  occurred,  two  small  vessels  only  requiring 
the  ligature. 

"  After  removal,  it  was  discovered  that  about  one-ha^f  of  the  surface 
which  plays  in  the  lower  end  of  the  tibia  had  been  fractured,  and  re- 
mained firmly  attached  to  the  extremity  of  that  bone,  and  as  it  was 
judged  that  the  efforts  to  remove  this  would  be  likely  to  produce  more 
injury  to  the  joint  than  would  arise  from  allowing  it  to  remain,  no 
attempt  was  made  to  extract  it. 

"The  joint  being  carefully  sponged  out,  the  sides  of  the  incision 
were  brought  accurately  together  by  means  of  sutures  and  adhesive 
straps,  after  which  simple  dressings  and  a  roller  were  applied,  and 
the  foot,  restored  to  its  natural  situation,  placed  in  a  fracture  box." 

Subsequently  that  portion  of  the  astragalus  which  was  permitted  to 
remain,  having  become  carious  and  loosened,  was  removed  also. 

The  case  continued  to  do  badly ;  all  the  bones  of  the  tarsus  and 
even  the  lower  ends  of  the  tibia  and  fibula  becoming  eventually  cari- 
ous; and  on  the  27th  of  March,  1853,  more  than  a  year  and  a  half 
after  the  receipt  of  the  injury,  the  leg  was  amputated ;  but  no  healthy 
action  ensued,  and  the  patient  soon  died.' 

The  result  of  this  case  can  scarcely  be  regarded  as  having  settled 
anything  in  reference  to  the  value  of  the  procedure  which  I  have  re- 
commended. For  reasons  which  seemed  satisfactory  to  the  surgeons 
who  made  the  operation,  only  one-half  of  the  broken  bone  was  re- 
moved ;  whether  the  result  would  have  been  different  if  the  whole 
had  been  at  once  taken  away,  we  cannot  now  determine.  I  have  related 
it,  however,'as  the  only  example  of  a  simple  fracture  with  displace- 
ment which  I  have  been  able  to  find  upon  record ;  and  in  this  case, 
several  surgeons  of  merited  distinction  concurred  in  the  opinion  that 
the  protruding  fragment  ought  to  be  removed. 

A  fracture  of  the  posterior  portion  of  the  calcaneum,  especially  when 
it  has  been  produced  by  muscular  action,  constitutes  an  exception  to 
fractures  of  the  tarsal  bones  generally,  and  demands  usually  that  appa- 
ratus of  some  kind  should  be  employed  in  its  treatment. 

In  order  to  replace  the  posterior  fragment  when  displaced,  or  to 
maintain  it  in  apposition  until  a  bony  union  is  accomplished,  it  will 
be  necessary  to  shorten  the  gastrocnemii  by  flexing  the  leg  upon  the 
thigh  and  extending  the  foot  upon  the  leg.  But  to  retain  the  limb  in 
this  position  it  will  be  expedient  always  to  employ  apparatus.     A 

'  Norris,  Amer.  Journ.  Med.  Sci.,  vol.  xx.  p.  379. 


FRACTURES    OF    THE    TARSAL    BONES. 


481 


Fig.  210. 


very  simple  contrivance,  however,  will  generally  answer  all  the  indi- 
cations. A  bandage,  padded  strap,  or  a  stuffed  collar,  may  be  fastened 
about  the  thigh  just  above  the  knee,  and 
made  fast  to  the  heel  of  a  slipper  by  a 
tape  (Fig.  210).  The  apparatus  is  the 
same  which  has  been  recommended  for  a 
rupture  of  the  tendo  Achillis. 

In  addition  to  this,  the  limb  ought  to 
be  covered  from  the  foot  upwards  as  far 
as  the  knee  with  a  snug  roller,  underneath 
which,  on  each  side  of  and  above  the 
detached  fragment,  ought  to  be  placed 
suitable  compresses,  the  object  of  the 
roller  being  to  diminish  muscular  con- 
traction, and  the  compresses  being  in- 
tended to  retain  the  detached  piece  in 
contact  with  the  main  body  of  the  bone. 

Some  surgeons  have  not  found  it  neces- 
sary to  flex  the  leg  upon  the  thigh,  and 
they  have  contented  themselves  with  ex- 
tending the  foot  upon  the  leg,  and  confin- 
ing it  in  this  position  by  a  splint  of  wood 
or  gutta  percha  laid  along  the  front  of  the 
leg,  ankle,  and  foot.  In  still  other  cases, 
the  fragment  has  shown  so  little  disposi- 
tion to  become  displaced  as  to  render  no 
precautions  of  any  kind  necessary,  except 
to  impose  upon  the  patient  complete  quiet, 
with  the  limb  resting  upon  its  outside  and 
flexed,  as  in  Pott's  fracture  of  the  fibula.  As  soon  as  the  inflammation 
has  sufficiently  subsided,  passive  motion  must  be  given  to  the  ankle  in 
order  to  prevent,  as  far  as  possible,  the  anchylosis  which  is  an  almost 
constant  result  of  these  accidents.  Indeed,  the  patient  is  fortunate 
who  recovers  a  tolerable  use  of  his  foot  after  the  lapse  of  many 
months,  nor  can  he  be  assured  that  the  inflammation  will  leave  these 
bones  and  their  dense  fibrous  envelops  for  a  long  period,  and  that  it 
may  not  result  in  caries  of  more  or  less  of  the  tarsal  bones,  demanding 
finally  amputation  of  the  whole  foot. 

We  have  not  intended  to  speak  in  this  place  of  those  severer  acci- 
dents, accompanied  with  comminution  and  extensive  laceration,  which 
;forbid  the  hope  of  saving  the  foot,  and  for  which  immediate  amputa- 
tion is  the  only  proper  resource,  but  which  constitute,  in  fact,  the  great 
majority  of  all  the  fractures  of  the  tarsal  bones. 


Apparatus  for  fracture  of  the  tube- 
rosity of  the  calcaneum. 


31 


482       FEACTUEES  OF  THE  METATAESAL  BONES. 


CHAPTER    XXXIV. 

FRACTURES  OF  THE  METATARSAL  BONES. 

These  bones  can  scarcely  be  broken  except  by  direct  blows,  and 
the  great  majority  of  their  fractures  are  the  results  of  severe  crushing 
accidents,  such  as  render  amputation  sooner  or  later  necessary.  Of 
those  which  do  not  demand  amputation,  by  far  the  largest  proportion 
are  compound  fractures ;  of  which  class  the  following  example  will 
serve  as  an  illustration. 

A  man  in  the  employ  of  one  of  the  railroads  which  connect  with 
this  city  was  run  over  by  a  loaded  car  on  the  14th  of  June,  1856, 
crushing  his  right  arm  so  as  to  render  its  immediate  amputation 
necessary.  I  found  also  a  compound  comminuted  fracture  of  the 
fourth  metatarsal  bone  of  the  right  foot.  Considerable  hemorrhage 
occurred  from  the  wound,  but  this  ceased  spontaneously.  Cool  water 
dressings  were  diligently  applied,  without  splints  or  bandages,  and, 
although  some  inflammation  and  suppuration  ensued,  the  parts  finally 
healed  over  and  the  fragments  united,  with  only  a  slight  backward 
displacement  at  the  seat  of  fracture. 

When  only  one  bone  is  broken,  the  displacement  is  usually  very 
trivial ;  but  when  several  are  broken,  it  may  be  considerable.  Mal- 
gaigne  relates  an  example  of  this  latter  accident  in  which,  the  three 
middle  bones  being  broken  by  the  wheel  of  a  carriage,  and  the  integu- 
ments being  badly  torn  and  bruised,  it  was  found  impossible  to  retain 
the  fragments  in  place.  The  patient  recovered,  and  was  able  to  place 
the  foot  well  to  the  ground,  but  the  proximal  fragments  continued  to 
project  upwards  upon  the  top  of  the  foot  to  such  a  degree  as  to  require 
a  special  shoe. 

In  a  majority  of  cases,  the  direction  of  the  displacement  is  backwards 
or  upwards,  especially  when  the  middle  metatarsal  bones  are  the  sub- 
jects of  the  fracture. 

I  have  in  my  cabinet  a  second  metatarsal  bone  broken  obliquely 
near  its  middle,  with  only  a  very  slight  displacement  of  the  lower 
fragment  backwards ;  and  also  a  cast  of  a  bone  which  has  united  with 
an  enormous  backward  projection. 

In  one  instance  I  have  seen  the  metacarpal  bone  of  the  little  toe 
cut  in  two  with  an  axe,  and  the  fragments  united  in  about  thirty  days, 
but  with  the  lower  fragment  slightly  displaced  outwards. 

Delamotte  relates  a  case  also  in  which  the  first  four  metatarsal 
bones  were  cut  off,  and  complete  union  was  accomplished  on  the 
fortieth  day:  at  the  end  of  two  months  the  patient  walked  without 
lameness. 

If  the  fragments  are  not  displaced,  nothing  is  required  except  that 


FEACTUEES    OF    THE    PHALANGES    OF    THE    TOES,  483 

the  foot  shall  be  kept  at  rest,  and  the  inflammation  controlled  by 
suitable  means. 

In  case,  however,  a  displacement  exists,  it  ought  to  be  remedied  if 
possible,  since  if  only  very  slight  it  may  become  the  source  of  a 
serious  annoyance.  If  the  fragments  project  upwards  they  interfere 
with  the  wearing  of  a  boot,  and  if  they  sink  toward  the  sole,  the 
skin  beneath  is  liable  to  remain  constantly  tender,  and  the  patient  may 
thus  be  seriously  maimed  for  life. 

In  case  the  displacement  is  not  due  to  the  action  of  the  muscles, 
but  only  to  the  nature  and  direction  of  the  force  producing  the  fracture 
or  to  entanglement  of  the  broken  ends,  and  it  is  likely  to  cause  any 
of  the  inconveniences  which  I  have  mentioned  if  permitted  to  remain, 
it  will  be  advisable  at  once  to  employ  considerable  force  in  the  way 
of  pressure,  or  to  elevate  the  fragments  through  an  opening  previously 
made  upon  the  dorsum  of  the  foot,  calling  to  our  aid  even  the  saw  or 
bone  cutters,  if  necessary.  After  which  the  fragments  may  be  re- 
tained in  place  by  carefully  applied  pasteboard  splints  and  compresses. 


CHAPTEH    XXXV. 

FRACTURES  OF  THE  PHALANGES  OF  THE  TOES. 

If  fractures  of  the  other  bones  of  the  foot  are  generally  of  such  a 
character  as  to  require  immediate  amputation,  these  fractures  demand 
this  extreme  resort  still  more  often.  Our  experience,  therefore,  in  the 
treatment  of  fractures  of  the  phalanges  of  the  toes  is  extremely 
limited. 

Lonsdale  observes  that  it  is  not  uncommon  to  find  great  irritation 
arise  after  fracture  of  the  great  toe ;  an  inflammation  extending  along 
the  absorbents  on  the  inside  of  the  leg  to  the  groin,  causing  abscesses 
to  form  in  different  parts  of  the  limb,  and  producing  sometimes  great 
constitutional  disturbance.  An  illustrative  case  has  come  under  my 
own  observation  at  the  Buffalo  Hospital  of  the  Sisters  of  Charity.  The 
patient,  Morgan  McMann,  set.  18,  was  admitted  Dec.  23,  1853,  having 
several  days  before  received  an  injury  upon  the  great  toe  which  con- 
tused the  flesh  severely  and  broke  the  first  phalanx.  He  was  then 
suffering  from  severe  pain  in  the  foot  and  leg,  and  the  absorbents 
were  inflamed  quite  to  the  groin.  Poultices  being  applied  to  the  foot 
and  cool  lotions  to  the  limb,  the  inflammation  soon  subsided,  but  not 
until  a  portion  of  the  toe  had  sloughed  away.  Eventually  also  it 
became  necessary  to  remove  some  portion  of  the  phalanx,  which  had 
died ;  after  which  the  wounds  healed  kindly. 


484  FEACTURES    OF    THE    PHALANGES    OF    THE    TOES. 

Wben  any  of  the  smaller  toes  are  broken,  it  will  be  found  easier  to 
support  the  fragments  by  a  broad  and  long  splint  which  shall  cover 
the  whole  sole  of  the  foot  and  all  the  toes  at  the  same  time,  than  to 
attempt  to  apply  a  splint  to  the  broken  toe  alone.  If,  however,  we 
prefer  this  latter  mode,  a  thin  piece  of  gutta  percha  will  be  found 
altogether  the  most  convenient  material  for  the  purpose. 

If  the  great  toe  is  broken,  its  great  breadth  may  prevent  any  dis- 
placement, and  a  well-moulded  gut^a-percha  splint  will  generally 
secure  a  perfect  and  rapid  union. 


PART    II. 


DISLOCATIONS. 


DISLOCATIONS. 


CHAPTER   I. 

GENERAL   CONSIDERATIONS. 

§  1.  General  Division  and  Nomenclature. 

A  DISLOCATION  is  the  displacement  of  one  bone  from  another  at  its 
place  of  natural  articulation. 

Dislocations  may  be  divided  into  accidental  or  traumatic,  sponta- 
neous or  pathologic,  and  congenital. 

Our  remarks  upon  the  etiology,  pathology,  symptomatology,  prog- 
nosis, and  treatment  of  these  injuries  must  be  considered  as  applicable 
only  to  accidental  or  traumatic  dislocations,  unless  the  fact  is  in  any 
case  otherwise  stated. 

"Accidental"  dislocations  are  those  in  which  the  bones  have  suffered 
displacement  in  consequence  of  the  application  of  a  sudden  force;  and 
surgeons  have  divided  these  accidents  into  Complete  and  Partial,  Sim- 
ple, Compound,  and  Complicated,  Recent  and  Ancient,  Primitive  and 
Consecutive, 

A  "complete"  dislocation  is  one  in  which  no  portions  of  the  articu- 
lar surfaces  remain  in  contact. 

A  "partial"  dislocation  is  one  in  which  the  articular  surfaces  are  not 
completely  removed  from  each  other. 

A  "simple"  dislocation  is  that  form  of  the  accident  in  which  the 
bone  has  only  slid  from  its  articulation,  and  is  accompanied  with  the 
least  or  only  an  average  amount  of  injury  to  the  soft  parts  or  to  the 
bones  adjacent  to  the  joint. 

A  "compound"  dislocation  implies  that  the  articulating  surface  of 
the  bone  has  been  thrust  through  the  flesh  and  skin,  or  that  in  some 
other  way  a  wound  has  been  made  which  communicates  with  the  joint. 

"Complicated"  dislocation  is  a  term  employed  by  some  writers  to 
designate  a  condition  wholly  differing  from  a  compound  dislocation, 
or,  in  some  cases,  a  condition  of  extra  complication.  Thus,  a  simple 
dislocation  may  be  complicated  with  a  fracture,  or  with  the  laceration 
of  an  important  bloodvessel,  &c.;  and  a  compound  dislocation  may  be 


488  GENEEAL    CONSIDERATIONS. 

complicated  in  the  same  way,  and  with  the  addition,  perhaps,  of  exten- 
sive laceration  and  destruction  of  integument,  muscles,  nerves,  &c. 

A  "recent"  luxation  has  taken  place  within  a  period  of  a  few  days, 
or,  at  most,  of  a  few  weeks;  and  an  "ancient"  luxation  has  existed  dur- 
ing a  longer  period;  the  exact  point  of  time  at  which  a  dislocation  shall 
be  called  recent  or  ancient  not  being  fully  determined  by  surgeons, 
and  the  application  of  these  terms  is  therefore  always  somewhat  arbi- 
trary. 

By  "primitive"  luxation  we  mean  that  the  bone  remains  nearly  or 
precisely  in  the  position  into  which  it  was  at  first  thrown ;  while  by 
"secondary"  or  "consecutive"  luxation  we  understand  that  it  has  sub- 
sequently, in  consequence  of  the  action  of  the  muscles,  or  from  un- 
successful efforts  at  reduction,  or  from  some  other  cause,  changed  its 
position  sufficiently  to  entitle  it  to  a  new  designation.  Thus  a  primi- 
tive dislocation  upon  the  ischiatic  notch  may  become  a  secondary 
dislocation  upon  the  dorsum  ilii,  or  the  reverse. 


§  2.  General  Predisposing  Causes. 

Age. — According  to  Malgaigne,  whose  conclusions  are  based  upon 
an  analysis  of  six  hundred  and  forty-three  cases,  dislocations  are  very 
rare  in  infancy,  only  one  having  occurred  under  five  years;  but  the 
frequency  increases  gradually  up  to  the  fifteenth  year,  from  this  period 
more  rapidly  up  to  the  sixty-fifth  year,  and  from  this  time  onward 
again  dislocations  become  more  rare.  He  has  mentioned  none  after 
the  ninetieth  year;  and  the  period  of  greatest  frequency  is  between 
the  thirtieth  and  sixty-fifth  year.  To  this  middle  period  belong  four 
hundred  and  seven  of  the  whole  number. 

The  inference  from  this  analysis  may  be  thus  briefly  stated:  age,  as 
a  predisposing  cause,  is  most  active  in  middle  life,  less  active  in  ad- 
vanced life,  and  least  active  of  all  in  early  life. 

It  is  proper,  however,  to  observe  that  while  such  statistics  may  be 
relied  upon  as  indicating  the  relative  frequency  of  these  accidents  at 
difl^'erent  periods  of  life,  they  cannot  be  regarded  as  determining  abso- 
lutely the  value  of  age  alone  as  a  predisposing  cause,  since  the  direct 
or  exciting  causes  may  be  more  active  at  one  period  than  another,  and 
in  some  measure  these  latter  causes  may  be,  and  doubtless  are,  respon- 
sible for  such  results. 

Constitution  and  Condition  of  the  Muscles  and  Ligaments. — It  may  be 
stated  as  a  general  fact  that  persons  of  feeble  constitutions,  and  whose 
muscular  systems  are  much  weakened,  suffer  dislocation  from  slighter 
causes  than  those  who  are  in  health,  and  whose  muscular  systems  are 
firm  and  vigorous;  and  that  a  relaxation  of  the  ligaments  which  sur- 
round a  joint,  however  this  may  have  been  occasioned,  predisposes  to 
dislocation.  Thus,  a  paralyzed  and  atrophied  limb  is  predisposed  to 
luxation ;  a  joint  in  which  the  capsule  has  become  stretched  by  effu- 
sions, or  by  violent  extension,  or  weakened  by  laceration  from  a 
previous  dislocation,  or  by  ulceration,  or  if  in  any  other  way  the 


GENERAL    SYMPTOMS.  489 

articulation  is  deprived  of  these  natural  protections,  we  need  scarcely 
say  that  it  is  thereby  rendered  more  liable  to  luxation. 

Ball  and  socket  joints,  other  things  being  equal,  are  more  liable  to 
displacement  than  ginglymoid;  but  then  much  more  depends  upon 
the  relative  exposure  of  the  joint  than  upon  its  anatomical  structure, 
so  that  the  elbow  is  much  more  frequently  dislocated  than  the  hip,  the 
shoulder-joint,  however,  being,  from  its  position  and  extent  of  motion, 
peculiarly  exposed,  and  being  also  a  ball  and  socket  joint,  is,  of  all 
others,  most  liable  to  dislocation. 


§  3.  Direct  or  Exciting  Causes. 

These  may  be  classed  under  two  general  heads,  namely,  external 
violence  and  muscular  action. 

External  violence  operates  either  directly  or  indirectly.  When  a 
person  falls  upon  the  knee  and  dislocates  the  head  of  the  femur,  the 
force  is  said  to  have  acted  indirectly,  and  this  is  by  far  the  most 
frequent  mode  of  dislocation  ;  but  when  the  blow  is  received  upon  the 
upper  end  of  the  humerus,  and  its  head  is  sent  into  the  axilla,  it  is 
said  to  have  been  dislocated  by  direct  violence. 

Muscular  action  produces  a  dislocation  slowly,  as  in  some  cases  of 
chronic  rheumatism,  and  then  it  is  called  a  spontaneous  or  pathologic 
dislocation;  or  suddenly,  as  in  the  violent  spasmodic  contractions 
which  accompany  convulsions;  or  sometimes  by  the  mere  voluntary 
effort  of  the  muscles;  and  these  latter  are  true  accidental  luxations. 

Tt  is  very  probable  that  external  force  can  seldom  be  regarded  as 
the  sole  cause  of  a  dislocation,  but  that,  in  a  large  majority  of  cases, 
muscular  action  consenting  with  the  shock,  performs  an  important 
role  in  the  history  of  the  accident.  The  limb  being  driven  obliquely 
across  its  socket  by  the  external  violence,  is  seized  by  the  stretched 
and  excited  muscles  with  such  vigor  as  to  contribute  not  a  little  to  the 
unfortunate  result.  Thus  it  will  be  found  that  the  same  force  which 
is  adequate  to  the  production  of  a  dislocation  in  the  living  and  healthy 
subject  is  wholly  insufficient  to  accomplish  the  same  in  the  dead ;  and 
a  man  who  is  fully  intoxicated  seldom  suffers  a  dislocation. 


§  4.  General  Symptoms. 

As  fractures  are  characterized  by  preternatural  mobility  and  crepi- 
tus, to  which  may  be  generally  added  the  circumstance  that,  when 
reduced,  the  fragments  will  not  remain  in  place  without  external 
support,  so,  on  the  other  hand,  dislocations  are  characterized  by  pre- 
ternatural rigidity,  an  absence  of  crepitus,  and  by  the  fact  that,  when 
reduced,  the  bone  does  not  generally  require  support  to  maintain  it  in 
position. 

These  three  are  the  usual,  and  they  may  be  termed  the  common, 
signs  of  distinction  between  fractures  and  dislocations,  but  no  one  of 
them  can  be  alone  depended  upon  as  positively  diagnostic.    Generally, 


490  GENERAL    CONSIDERATIONS, 

when  a  bone  has  been  dislocated,  we  shall  find  the  limb  in  a  certain 
position,  which  is  uniform  for  all  dislocations  of  the  same  character, 
and  almost  immovably  fixed ;  but  when  the  ligaments  and  muscles 
about  the  joint  have  been  extensively  torn,  or  the  whole  body  is  still 
suffering  under  the  shock,  or  in  any  other  circumstances  where  the 
power  of  the  muscles  is  weakened,  this  rigidity  may  give  place  to 
extreme  mobility. 

True  crepitus  does  not  exist  without  a  fracture,  but  it  is  not  always 
present  in  fractures,  and  there  is  often  a  sensation  produced  in  the 
rubbing  and  chafing  of  dislocated  bones  which  very  much  resembles 
certain  kinds  of  crepitus,  and  by  the  inexperienced  has  been  often 
mistaken  for  it.  I  allude  to  the  subdued  rasping  sound  or  sensation 
which  is  found  generally  on  the  second  or  third  day,  and  sometimes 
earlier,  and  which  is  the  result  of  fibrinous  effusions,  or,  perhaps,  in 
some  instances,  of  the  mere  rubbing  of  firmly  compressed  ligamentous 
and  cartilaginous  surfaces  upon  each  other.  The  crepitus  of  a  recent 
fracture  can  be  scarcely  confounded  with  this  obscure  sensation,  unless 
it  is  in  some  cases  of  incomplete  fracture,  or  of  a  fracture  situated 
remote  from  the  surface,  as  in  the  case  of  the  hip;  but  a  fracture 
which  is  a  few  days  old,  whose  surface  has  become  softened  by  in- 
flammation and  more  or  less  covered  with  lymph,  and,  when  the 
rigidity  is  great,  may  sometimes  deceive  the  most  experienced  surgeon, 
so  exactly  will  it  be  found  to  imitate  the  sensations  produced  by  the 
chafing  of  an  inflamed  joint,  or  of  closely  approximated  fibrous 
surfaces. 

I  have  said  that  a  true  crepitus  does  not  exist  without  a  fracture ; 
but  then  a  very  minute  fracture,  such  as  the  detachment  of  a  scale  of 
bone  by  the  tearing  away  of  a  tendon  or  of  a  ligament,  may  produce 
crepitus ;  or  even  the  separation  of  a  piece  of  cartilage  may  sufficiently 
expose  the  bone  to  determine  the  presence  of  this  phenomenon.  These 
are,  however,  no  longer  examples  of  simple  dislocation. 

Nor  are  the  two  reverse  propositions,  in  relation  to  the  retention  of 
the  bones  in  place,  invariable  in  their  application.  A  broken  bone, 
well  reduced,  does  not  always  manifest  a  tendency  to  displacement, 
nor  does  a  dislocated  limb,  when  restored  to  its  socket,  in  all  cases 
maintain  its  position  without  support. 

The  other  general  signs  of  dislocation  are  pain,  swelling,  and  dis- 
coloration. The  pain  is  generally  more  intense  in  dislocations  than 
in  fractures,  the  expanded  end  of  the  bone  resting  often  upon  one  or 
more  large  nerves,  which  usually,  with  the  arteries,  approach  very 
near  the  joints,  this  pressure  being  also  greatly  increased  by  the 
extreme  tension  of  the  muscles.  Not  unfrequently  numbness  and 
temporary  paralysis  of  the  whole  limb  are  the  consequences.  In 
other  cases  the  pain  is  due  solely  to  the  pressure  upon  the  muscles  or 
to  the  tension  of  the  muscles,  or,  perhaps,  to  the  tension  of  the  untorn 
ligaments  and  capsule. 

Grenerally,  the  limb  is  shortened,  but  in  a  few  cases  it  is  found 
slightly  lengthened,  while  the  natural  axis  of  the  bone  with  its  socket 
is  always  changed.  If  examined  early,  and  before  the  supervention 
of  swelling,  the  joint  end  of  the  displaced  bone  may  be  felt  in  its 


: 


PATHOLOGY.  491 

unnatural  position,  and  a  corresponding  depression  may  be  discovered 
in  the  situation  of  the  articulation,  especially  if  the  bones  are  super- 
ficial. 

§  5.  Pathology. 

The  dissection  of  recent  dislocations  produced  by  external  violence, 
shows  the  capsular  ligament  more  or  less  torn,  and  also  a  rupture  of 
some  of  the  lateral  and  other  short  ligaments,  with  a  complete  rupture 
in  most  cases  of  some  of  the  tendons  which  immediately  surround  the 
joint,  or  of  those  which  are  attached  to  the  capsule:  the  muscles, 
nerves,  arteries,  &c.,  through  which  the  bone  in  its  passage  has  passed, 
or  upon  which  it  is  found  resting,  being  also  contused,  stretched,  or 
torn  asunder. 

This  description,  however,  does  not  apply  to  dislocations  produced 
by  muscular  action  alone,  in  a  majority  of  which  cases  the  capsule  is 
only  stretched,  and  not  torn,  and  no  lesions  of  other  structures  are 
necessarily  present. 

If  the  fracture  remains  unreduced,  the  margins  of  the  old  socket,  in 
the  case  of  enarthrodial  articulations,  become  gradually  depressed  while 
the  concavity  of  the  socket  is  filling  in  with  a  fibrous  or  bony  tissue, 
until  at  length  the  whole  of  this  portion  of  the  joint  apparatus  is  nearly 
or  entirely  removed.  This  process  is  generally  very  slow,  and  may 
not  be  consummated  until  after  the  lapse  of  many  years. 

At  the  same  time,  but  with  much  greater  rapidity,  the  head  of  the 
bone  in  its  new  position,  and  the  soft  or  hard  parts  upon  which  it  rests, 
are  undergoing  certain  changes  to  adapt  them  to  their  new  relations, 
and  calculated  in  some  measure  to  restore  the  limb  to  its  normal  func- 
tions. If  the  head  of  the  bone  rests  upon  muscle,  the  cellular  and 
fibrous  tissues  which  enter  into  the  composition  of  the  muscle  become 
condensed  and  thickened,  forming  a  shallow  or  elongated  cup,  whose 
margins  are  attached  to  the  neck,  or  shaft  of  the  bone,  and  whose  walls 
are  lubricated  with  synovia.  If  it  rests  upon  bone,  by  a  process  of 
interstitial  absorption  a  true  socket  is  formed,  sometimes  deep  and 
sometimes  shallow,  whose  edges,  receiving  additional  ossific  deposi- 
tions, become  lifted  so  as  to  form  a  rim.  At  the  same  time  the  head 
of  the  bone  is  undergoing  corresponding  changes,  to  adapt  itself  to  the 
newly-formed  socket;  it  is  flattened  or  otherwise  changed  in  form,  and 
in  the  progress  of  this  change  its  natural  secreting  and  cartilaginous 
surfaces  are  gradually  removed,  a  porcellanous  deposit  taking  its  place. 
The  same  kind  of  hard,  polished,  ivory-like  deposit  is  found  also  in 
those  portions  of  the  new  socket  which  have  been  especially  exposed 
to  pressure  and  friction.  Instead  of  the  eburnation,  an  imperfect  fibro- 
serous  surface  or  synovial  capsule  may  be  formed. 

I  have  in  my  cabinet  an  example  of  ancient  luxation  of  the  hip-joint 
in  which  the  head  of  the  femur,  having  rested  upon  the  dorsum  ilii,  has 
formed  a  nearly  flat  but  smooth  surface — a  kind  of  elevated  plateau ; 
in  other  cases  I  have  seen  the  margins  of  the  new  socket  so  elevated 
as  to  rest  against  the  neck  of  the  femur,  and  completely  lock  it  in. 

Consenting  with  these  changes,  and  in  consequence  partly  of  the 


492  GENEEAL    CONSIDEEATIONS. 

disuse  of  the  limb,  the  muscles,  and  even  the  bones  sometimes,  suffer 
a  gradual  atrophy.  In  some  measure  these  alterations  may  be  due 
also  to  the  pressure  of  the  dislocated,  bone  upon  arterial  and  nervous 
trunks,  by  which  their  functions  become  partially  or  completely  anni- 
hilated, and  their  structure  even  may  be  wholly  obliterated.  In  conse- 
quence also  of  the  inflammation  which  immediately  results,  we  ought 
not  to  omit  to  notice  that  the  large  trunk  of  an  artery  sometimes 
becomes  firmly  adherent  to  the  capsule  or  periosteum  of  a  displaced 
bone,  and  its  reduction  is  attended  with  imminent  danger  of  laceration 
and  of  a  fatal  hemorrhage.  Numerous  instances  of  this  grave  accident, 
especially  in  attempts  to  reduce  old  dislocations  of  the  shoulder-joint, 
are  upon  record. 


§  6.  General  Prognosis. 

We  shall  study  the  prognosis  of  these  accidents  to  better  advantage 
when  we  come  to  speak  of  the  individual  bones  and  their  various 
forms  of  dislocation ;  but  it  is  proper  to  state  in  this  place,  generally, 
that  very  few  joints,  having  been  once  completely  displaced  from  their 
sockets  by  external  violence,  are  ever  so  completely  restored  as  not  to 
leave  some  traces  of  the  accident  for  many  years,  if  not  for  the  whole 
of  the  subsequent  life  of  the  patient,  either  in  the  partial  limitation  of 
their  motions,  or  in  the  diminished  size  and  power  of  the  muscles  of 
the  limbs,  or  in  the  presence  of  an  occasional  arthritic  pain  :  the  degree 
and  permanence  of  these  sequences  depending  upon  the  joint  which  is 
the  subject  of  the  displacement,  the  extent  of  the  original  injury,  the 
length  of  time  it  has  remained  unreduced,  the  means  employed  in  its 
reduction,  the  health  and  condition  of  the  patient,  with  so  many  other 
contingent  circumstances  as  to  preclude  the  idea  of  a  complete  specifi- 
cation. 

If  the  bone  is  not  reduced,  a  permanent  maiming  is  inevitable;  but 
it  is  surprising  how  much  time  and' the  intelligent  processes  of  nature 
can  eventually  accomplish  toward  a  restoration  of  the  natural  func- 
tions, especially  when  aided  by  a  good  constitution  and  judicious 
treatment.  If  the  symmetry  of  form  and  grace  of  motion  are  never 
replaced,  the  value  of  the  limb,  for  all  the  practical  purposes  of  life, 
is  not  unfrequently  completely  re-established. 


§  1.  General  Treatment. 

The  first  indication  of  treatment  is  to  reduce  the  bone.  Whatever 
delays  may  be  proper  or  justifiable  in  certain  cases  of  fracture,  such 
delays  are  never  to  be  argued  in  cases  of  dislocation.  The  sooner  the 
reduction  is  accomplished,  the  better.  For  this  purpose  we  resort  at 
once  to  such  manipulations  or  mechanical  contrivances  as  the  nature  of 
the  case  demands;  and  if  these  fail,  or  if  at  the  first  they  are  deemed 
insufficient,  we  invoke  the  aid  of  constitutional  means,  or  such  as  are 
calculated  to  diminish  the  power  and  antagonism  of  the  muscles. 


GENERAL    TREATMENT.  493 

Many  dislocations  may  be  reduced  promptly  by  m.anipulation  alone; 
which  mode  is  always  to  be  preferred  when  it  will  prove  sufficient, 
for  the  reasons  that  it  is  generally  the  least  painful  to  the  patient,  and 
the  least  apt  to  inflict  additional  injury  upon  the  muscles  and  liga- 
ments. 

A  person  wholly  unacquainted  with  anatomy  or  surgery,  may 
occasionally  succeed  in  reducing  a  dislocated  limb;  indeed,  it  fre- 
quently happens  that  the  patient  himself,  by  mere  accident  in  getting 
up  or  in  lying  down,  accomplishes  the  reduction;  and  even  in  a  very 
large  majority  of  cases  force  and  perseverance  will  finally  succeed  by 
whomever  they  may  be  employed;  but  the  observing  student  of  suro-ery 
will  soon  discover  the  difference  between  accident  and  brute  force  on 
the  one  hand,  and  intelligent  manipulation  on  the  other.  The  char- 
latan bone-setter  does  not  often  allow  himself  to  fail,  unless  the  cour- 
age of  his  patient  gives  out,  or  he  ignorantly  supposes  the  reduction 
to  be  effected  when  it  is  not ;  but  his  success,  achieved  through  great 
and  unnecessary  suffering,  is  often  obtained,  also,  at  the  expense  of 
the  limb.  While  the  surgeon  whose  knowledge  of  anatomy  enables 
him  to  understand  in  what  direction  the  muscles  are  offering  resist- 
ance, and  through  what  ligaments  the  head  of  the  bone  must  be 
guided,  lifts  the  limb  gently  in  his  hands,  and  the  bone  seeks  its 
socket  promptly  and  without  disturbance,  as  if  it  needed  only  the 
opportunity  that  it  might  demonstrate  its  willingness  to  return. 

We  must  understand  not  only  what  muscles  and  ligaments  antag- 
onize the  reduction,  if  we  would  be  most  successful,  but  also  what 
muscles,  by  being  provoked  to  contraction,  will  themselves  aid  in  the 
reduction.  In  short,  to  become  expert  bone-setters  in  the  department 
of  dislocations,  one  must  possess  a  complete  knowledge  of  the  phy- 
siognomy or  the  external  aspect  of  joints,  acquired  only  by  repeated 
and  careful  examinations,  he  must  be  familiar  with  the  anatomy  and 
functions  of  the  muscles,  he  must  understand  thoroughly  the  ligaments, 
he  must  have  experience,  tact,  and  fertility  of  resource. 

Without  these  qualifications  he  will  do  better  never  to  undertake 
to  treat  dislocations,  since  he  is  constantly  liable  to  mistake  fractures 
for  dislocations,  and  dislocations  for  fractures ;  he  will  submit  a 
sprained  wrist  to  violent  extensions  under  the  conviction  that  the 
joint  is  displaced ;  he  will  mistake  natural  projections  for  deformities, 
and  fail  to  recognize  the  real  deformity  when  it  actually  exists ;  he 
will  leave  bones  unreduced,  fully  believing  that  they  are  reduced ;  and 
he  will  all  in  all,  within  a  few  years,  accomplish  vastly  more  evil  than 
he  can  ever  do  good.  Let  a  man  practice  any  other  branch  of  surgery 
if  he  will,  without  experience  or  scientific  knowledge,  but  he  must 
not  attempt  to  reduce  dislocated  bones.  The  most  learned  and  the 
most  skilful  we  shall  find  falling  into  error,  embarrassed  by  the  un- 
certainty of  the  diagnosis,  or  successfully  resisted  by  the  power  of  the 
opposing  agents ;  what  then  can  be  expected  of  those  who  are  both 
ignorant  and  inexperienced,  but  failures  and  disasters? 

As  a  means  of  disarming  the  muscles,  or  of  placing  them  off  their 
guard,  we  often  practise  successfully  the  diversion  of  the  mind  of  the 
patient.     At  the  very  moment  that  the  limb  is  moved  or  extension  is 


494 


GENEEAL    CONSIDEEATIONS. 


Fig.  211. 


made,  a  question  is  addressed  to  him,  or  he  may  be  suddenly  sur- 
prised by  some  unexpected  intelligence. 

Extension  and  counter-extension,  made 
with  our  own  hands  or  with  the  hands  of 
assistants,  constitute  the  second  resort  where 
manipulation  alone  has  failed.  The  surgeon, 
seizing  upon  the  limb  firmly  with  his  hands, 
makes  the  extension,  while  the  assistants 
make  the  counter-extension ;  or,  instead  of 
grasping  the  limb  directly,  the  operator  may 
use  for  this  purpose  circular  and  longitudinal 
bandages,  or  the  bandage  or  handkerchief  tied 
in  the  form  of  the  clove  hitch  (Fig.  211).  Exten- 
sion is  thus  applied  in  connection  with  mani- 
pulation, aided,  perhaps,  by  direct  pressure 
upon  the  head  of  the  displaced  bone.  Failing 
in  this,  we  employ  some  one  of  the  various 
mechanical  contrivances  which,  while  they 
are  capable  of  exerting  much  more  power, 
possess  also  the  important  advantage  of  ope- 
rating gradually  and  steadily,  by  which  mode 
the  resistance  of  the  muscles  is  always  more 
speedily  and  more  completely  overcome. 

For  this  purpose  surgeons  employ  generally 
in  the  case  of  the  large  limbs,  the  compound 
pulleys  (Fig.  212),  or  the  simple  rope  windlass, 
which  is  thus  described  by  Dr.  Gilbert,  of  Philadelphia:  "Place  the 
patient,  and  adjust  the  extending  and  counter-extending  bands  as  for 

Fig.  212. 


Clove  hitcli.     (From  Erichsen.) 


Compound  pulleys  and  ring  to  which  one  end  of  the  pulley  rope  is  fastened. 

the  pulleys;  then  procure  an  ordinary  bed-cord  or  a  wash-line,  tie  the 
ends  together  and  again  double  it  upon  itself,  pass  it  through  the  ex- 
tending tapes  or  towels,  doubling  the  whole  once  more,  and  fasten  the 
distal  end,  consisting  of  four  loops  of  rope,  to  a  window-sill,  door-sill, 
or  staple,  so  that  the  cords  are  drawn  moderately  tight;  finally,  pass 
a  stick  through  the  centre  of  the  double  rope,  then  by  revolving  the 


DOUBLE    OR    BILATERAL    DISLOCATION.  495 

stick  as  an  axis  or  double  lever,  tlie  power  is  produced  precisely  as 
it  should  be  in  such  cases,  viz.,  slowly,  steadily,  and  continuously." 

Jarvis's  adjuster,  although  very  complex  and  expensive,  possesses 
some  advantages  over  the  pulleys,  which  may,  perhaps,  entitle  it  to 
the  preference  in  some  cases. 

Among  the  constitutional  means,  ether  and  chloroform  occupy  the 
first  rank ;  indeed  they  are,  at  the  present  day,  almost  the  only  means 
of  this  class  to  which  surgeons  resort,  and  their  value  in  this  point 
of  view  can  scarcely  be  over-estimated.  Only  when  some  unusual  cir- 
cumstance or  condition  of  the  patient  forbade  the  use  of  an  anaesthetic, 
would  the  surgeon  return  to  the  ancient  practice  of  bleeding  ad  de- 
Uquium,  of  prostrating  the  system  with  antimony,  or  to  the  use  of  those 
vastly  less  efficient  agents,  opium  and  the  warm  bath. 


CHAPTEE,    II. 

DISLOCATIONS    OF  THE    LOWER   JAW. 

There  are  two  principal  forms  of  this  dislocation,  namely,  the  double 
or  bilateral  dislocation,  and  the  single  or  unilateral ;  in  both  of  which 
the  direction  of  the  displacement  is  forwards.  To  these  there  has 
been  added  one  example  of  an  outward  displacement  accompanied 
with  a  fracture.^ 

§  1.  Double  or  Bilateral  Dislocation. 

This  form  of  dislocation  of  the  lower  jaw  is  much  the  most  frequent, 
being  met  with  in  about  two  out  of  every  three  cases.  It  appears  also 
to  occur  oftener  in  women  than  in  men,  and  usually  between  the  twen- 
tieth and  thirtieth  je&r  of  life.  In  infancy  and  extreme  old  age  it  is 
exceedingly  rare;  yet  Sir  Astley  Cooper  mentions  a  case  in  which 
"two  boys"  being  at  play,  one  had  an  apple  thrust  into  his  mouth, 
producing  a  double  dislocation;  and  Nelaton  saw  the  same  accident  in 
an  old  man  of  seventy-two  years,  who  was  toothless. 

This  comparative  immunity  in  youth  and  old  age  has  been  ascribed 
to  certain  peculiarities  in  the  form  of  the  jaw  at  these  periods  of  life. 
Nelaton  attributes  its  more  frequent  occurrence  in  middle  life  to  the 
great  length  and  strong  anterior  inclination  of  the  coronoid  process. 

In  a  majority  of  cases  the  direct  or  immediate  cause  has  seemed  to 
be  muscular  action  alone.     Malgaigne  found  this  cause  to  prevail  in 

'  Robert,  Journal  de  Chir.,  1844. 


496  DISLOCATIONS    OF    THE    LOWEE   JAW. 

twenty-five  out  of  forty  cases ;  and  of  the  twenty-five  cases  fifteen 
were  occasioned  by  gaping,  five  by  convulsions,  four  by  vomiting,  and 
one  by  rage.  Dr.  Physick,  of  Philadelphia,  found  both  condyles  dis- 
located in  a  woman  in  consequence  of  the  violent  gesticulation  of  her 
jaw  while  scolding  her  husband.  But  in  a  more  remarkable  case  still, 
this  surgeon  found  the  jaw  dislocated  after  recovery  from  a  profase 
salivation,  and  of  the  cause  of  which,  or  the  time  of  its  occurrence, 
the  patient,  a  young  girl,  could  give  no  account.  Dr.  Physick  made 
several  ineffectual  attempts  at  reduction,  and  only  succeeded  at  last 
after  he  had  made  her  completely  intoxicated  with  ardent  spirits.^ 

Dr.  E.  Andrews,  of  Michigan,  found  both  condyles  dislocated  by  a 
lobelia  emetic.  The  patient  had  often  taken  these  emetics  before,  and 
had  frequently  experienced  a  sensation  "of  catching"  at  the  joint,  but 
the  jaw  had  always  until  this  time  resumed  its  position  spontaneously,^ 

Among  the  causes  from  outward  violence,  the  introduction  of  some 
foreign  body  into  the  mouth,  and  the  extraction  of  teeth,  occupy  the 
most  important  place.  In  fifteen  cases,  seven  were  from  the  former 
and  six  from  the  latter  cause. 

My  late  pupil,  A.  W.  Gilbert,  has  related  a  case  which  came  under 
his  own  observation,  produced  by  a  similar  cause.  During  his  appren- 
ticeship with  Dr.  Parsons,  a  dentist,  he  was  requested  to  insert  a  set  of 
teeth  for  a  young  man  residing  in  Cattaraugus  Co.,  N.  Y.,  and  while 
opening  his  mouth  to  take  an  impression  of  his  gums,  he  dislocated 
"both  condyles  forwards,  under  the  zygomatic  arches;"  but  so  perfectly 
were  the  muscles  relaxed,  that  he  immediately  reduced  them,  without 
the  least  difficulty,  by  placing  his  thumbs  as  far  back  as  possible  upon 
the  molar  teeth,  depressing  the  back  part  of  the  jaw,  and  at  the  same 
moment  elevating  the  chin.^ 

The  late  Prof.  James  Webster,  of  Rochester,  N.  Y.,  dislocated  the 
jaw  of  a  lady  while  attempting  to  pry  out  a  root  of  one  of  the  molars. 

Pathology. — In  order  that  we  may  better  understand  the  pathology 
of  this  accident,  it  will  be  proper  to  say  a  few  words  in  relation  to  the 
anatomy  of  the  temporo-maxillary  articulation  and  the  other  parts 
concerned  in  the  dislocation  now  under  consideration. 

The  articulation  is  formed  by  the  condyloid  process  of  the  inferior 
maxilla  and  the  glenoid  fossa  of  the  temporal  bone,  in  front  of  which 
fossa,  and  at  the  root  of  the  zygomatic  arch,  is  a  slight  elevation,  called 
the  articular  eminence.  Between  the  joint  surfaces,  both  of  which  are 
covered  with  a  cartilage  of  incrustation,  is  placed  an  interarticular 
cartilage,  which  divides  the  joint  into  two  cavities,  one  corresponding 
to  the  condyle  of  the  inferior  maxilla,  and  the  other  to  the  glenoid 
fossa,  each  of  which  is  furnished  with  a  distinct  synovial  membrane. 

Properly  there  is  but  one  ligament — namely,  the  external  lateral — 
which  passes  from  the  outer  surface  of  the  articular  eminence  to  the 
corresponding  surface  of  the  neck  of  the  condyle.  What  is  called  the 
internal  lateral  ligament  arises  from  the  apex  of  the  spinous  process  of 
the  sphenoid  bone,  and  is  inserted  into  the  margin  of  the  dental  fora- 

'  Physick,  Dorsey's  Elements  of  Surgery,  vol.  i.  p.  202.     Philadelphia,  1813. 

^  Andrews,  Peninsular  Journ.  Med.,  vol.  iii.  p.  101.     1855. 

^  Gilbert,  Thesis,  on  Dislocation  of  the  Inf.  Max.     University  of  Buffalo,  1858. 


DOUBLE    OR    BILATEEAL    DISLOCATION. 


497 


men,  and  has  therefore  no  immediate  connection  with  the  articulation, 
although  it  tends  to  strengthen  the  joint.  The  same  is  true  of  the 
stylo-maxillary  ligaments. 

The  lower  jaw  is  drawn  upwards,  or  closed  upon  the  upper  jaw,  by 
the  action  of  the  temporal,  masseter,  and  internal  pterygoid  muscles; 
it  is  drawn  downwards  by  the  action  of  the  digastricus,  mylo-hyoideus, 
and  genio-hyoglossus  muscles;  forwards  by  a  few  fibres  of  the  masseter 
and  by  the  external  pterygoid  muscles;  and  laterally  by  the  alternate 
action  of  the  external  and  internal  pterygoid  muscles. 

When  the  mouth  is  open  to  its  utmost  extent,  the  maxillary  condyle 
rises  upon  the  articular  eminence  until  it  rests  upon  its  very  summit. 
Indeed,  it  is  probable  that  in  most  persons  it  advances  rather  in  front 
of  the  centre  of  the  eminence ;  so  that  in  order  to  become  actually  dis- 
located it  only  needs  that  the  capsule  shall  be  somewhat  relaxed,  or 
that  it  shall  actually  give  way  in  front,  when  the  condyles  slide  for- 
wards and  occupy  a  position  directly  in  front  instead  of  behind  this 
eminence. 

It  is  easy  to  comprehend  how  the  combined  action  of  the  two  ex- 
ternal pterygoid  muscles,  with  a  portion  of  the  fibres  of  the  masseter, 
may  alone  produce  the  dislocation  when  the  mouth  is  wide  open,  and 
especially  when,  in  consequence  of  a  slight  blow  upon  the  chin,  the  an- 
terior portion  of  the  capsule  becomes  lacerated;  for  it  must  be  noticed 
that  the  ascending  ramus,  with  its 

prolonged  condyloid  process,  con-  Pig-  213. 

stitutes  a  lever  of  the  first  kind, 
in  which  the  temporal  muscle, 
attached  to  the  coronoid  process, 
the  masseter,  and  even  the  mas- 
toid process,  constitute  the  ful- 
crum, the  anterior  portion  of  the 
capsule,  the  weight,  and  the  force 
acting  against  the  front  of  the 
chin,  the  power. 

In  this  position  of  the  condyle, 
drawn  upwards  and  forwards  by 
the  action  of  the  pterygoid  and 
temporal  muscles,  the  chin  de- 
scends toward  the  neck,  and  the 
coronoid  process  rests  against  the  back  of  the  superior  maxilla,  or 
against  the  malar  bone  at  the  point  of  its  junction  with  the  upper 
maxillary.  The  temporal,  masseter,  and  internal  pterygoid  muscles 
are  very  much  upon  the  stretch,  if  not  more  or  less  lacerated. 

Symptoms. — The  mouth  is  widely  open  and  the  jaw  nearly  immovable. 
It  has  been  noticed  generally  that  the  chin  may  be  slightly  depressed, 
but  that,  owing  probably  to  the  pressure  of  the  coronoid  process 
against  the  body  of  the  upper  maxilla,  or -against  the  malar  bone,  it  is 
generally  impossible  to  elevate  the  jaw  in  any  degree  whatever. 

The  jaw  is  also  slightly  advanced ;  a  depression,  covering  a  con- 
siderable space,  exists  between  the  auditory  canal  and  the  posterior 
margin  of  the  condyle.     A  slight  fulness  is  observed  in  the  temporal 
32 


Double  dislocation  of  the  inferior  maxilla. 


498 


DISLOCATIOlsrS    OF    THE    LOWER   JAW. 


Fig.  214. 


fossa  and  also  upon  the  side  of  the  cheek  in  the  region  of  the  masseter 
muscle. 

Ordinarily  the  patient  suffers  considerable  pain,  but  not  always,  from 

the  pressure  of  the  condyles  upon  the 
branches  of  the  temporal  nerves. 
There  is  a  constant  flowing  of  the 
saliva  from  the  mouth ;  the  patient 
is  unable  to  articulate,  and  even 
deglutition  is  performed  with  great 
difficulty. 

Prognosis. — When  the  dislocation 
remains  unreduced,  the  lower  jaw 
gradually  approximates  the  upper, 
and  its  anterior  projection  sensibly 
diminishes,  the  saliva  ceases  to  drib- 
ble from  the  mouth,  deglutition  and 
speech  are  restored,  mastication  is 
performed  with  considerable  ease,  and 
in  short,  the  patient  comes  at  length 
to  experience  no  great  inconvenience 
from  the  displacement. 

Robert  Smith  relates  the  case  of  a 
woman  whose  lower  jaw  was  dislo- 
cated during  an  epileptic  convulsion. 
She  was  at  the  time  in  one  of  the 
metropolitan  hospitals,  but  the  accident  was  not  noticed  by  the  sur- 
geons, and  it  remained  ever  afterwards  unreduced.  At  the  end  of  a 
year  she  could  close  the  lips  perfectly,  but  was  able  to  open  the  mouth 
only  to  a  limited  extent ;  the  teeth  of  the  lower  jaw  remained  advanced, 
but  the  involuntary  flow  of  saliva  had  ceased,  and  the  faculty  of  speech 
had  been  regained.'  In  Professor  Webster's  case,  to  which  I  have 
before  referred,  although  the  jaw  was  immediately  and  easily  reduced, 
after  the  lapse  of  several  years  when  I  saw  the  lady,  she  still  com- 
plained that  it  hurt  her  whenever  she  eat,  and  that  she  often  felt  the 
condyles  slip  in  their  sockets. 

Eeduction  has  been  accomplished  by  Physick  in  the  case  already 
related  after  the  lapse  of  several  weeks ;  Sir  Astley  reduced  a  double 
dislocation  after  one  month  and  five  days,  which  had  been  overlooked 
by  the  surgeon  in  attendance  f  and  Donovan  succeeded  after  ninety- 
eight  days.^ 

Treatment. — Reduction  may  generally  be  accomplished  with  ease  in 
cases  of  recent  luxation,  in  the  following  manner:  The  patient  being 
seated  upon  the  floor  with  his  head  between  the  knees  of  the  operator, 
a  couple  of  pieces  of  cork,  gutta  percha,  or  pine  wood  are  placed  as 
far  back  between  the  molars  as  possible,  when  the  surgeon  seizing 
upon  the  chin  draws  it  steadily  upwards,  taking  care  not  to  draw  it  i 


Double  dislocation  of  the  inferior  maxilla. 


'  Robert  Smith,  on  Fractures  and  Dislocations.     Dublin,  1854,  p.  288. 
^  Sir  Astley  Cooper,  on  Disloc.  and  Frac. ;  Amer.  ed.,  p.  816. 

3  Donovan,  Amer.  Journ.  Med.  Sci.,  Oct.  1842,  p.  470 ;  from  Dublin  Med.  Press, 
May  25,  1842. 


DOUBLE    OE    BILATEEAL    DISLOCATIOISr.  499 

forwards  at  the  same  time,  since  by  tins  movement  he  would  resist 
the  action  of  the  muscles  which  naturally  tend  to  restore  it  to  place 
whenever  the  condyloid  processes  are  lifted  sufficientlj  from  the 
zygomatic  fossse.  Many  surgeons  prefer  to  sit  or  stand  in  front  of 
the  patient,  and  depress  the  condyles  by  means  of  the  thumbs  placed 
inside  of  the  mouth  and  upon  the  tops  of  the  molars.  If  the  thumbs 
\  are  used  in  this  way,  it  would  be  well  to  protect  them  with  a  piece  of 
'  leather,  or  to  slip  them  off  from  the  teeth  suddenly  when  the  condyles 
are  gliding  into  their  places,  as  the  muscles  sometimes  close  the  mouth 
with  sufficient  violence  to  bruise  severely  anything  which  might  at 
this  moment  be  interposed  between  the  teeth. 

The  method  practiced  by  Eavaton,  of  simply  lifting  the  chin  gradu- 
ally and  forcibly  toward  the  upper  jaw,  was  essentially  the  same,  but 
far  less  efficient ;  for  although  he  placed  nothing  between  the  molars 
to  serve  as  a  fulcrum,  the  backmost  teeth  themselves  must  in  some 
degree  perform  this  service  whenever  the  lower  jaw  being  dislocated 
and  drawn  upwards,  the  chin  is  forcibly  approximated  toward  the 
upper. 

In  other  cases  it  has  been  found  necessary  first  to  disengage  the 
coronoid  process,  by  depressing  the  chin  gently,  and  then  pressing 
backwards  in  the  direction  of  the  articulation  ;  a  method  which  would 
certainly  deserve  a  trial  in  case  of  the  failure  of  that  first  described. 
This  was  the  method  practiced  by  Hippocrates. 

A  more  effectual  expedient,  however,  consists  in  reducing  one  side 
at  a  time ;  taking  good  care  always  that  the  side  first  reduced  is  not 
reluxated  while  the  attempt  is  being  made  to  reduce  the  other,  a  thing 
which  happened  in  one  of  the  cases  treated  by  Sir  Astley  Cooper,  and 
has  happened  many  times  in  the  practice  of  other  surgeons. 

Finally,  if  all  other  expedients  fail,  we  ought  not  to  hesitate  to 
resort  to  anassthetics,  nor  indeed  could  any  objection  exist  to  their 
employment  at  any  period  of  the  treatment,  were  it  not  that  in  a  large 
majority  of  cases  the  reduction  is  effected  so  easily  and  promptly  as  to 
render  their  employment  wholly  unnecessary. 

After  the  reduction  is  accomplished,  it  will  be  a  matter  of  wise  pre- 
caution to  sustain  the  jaw  by  a  double-headed  bandage  passed  under 
the  chin,  and  secured  upon  the  top  of  the  head,  so  as  to  prevent  the 
mouth  from  being  accidentally  opened  too  far,  especially  during  sleep, 
since  experience  has  shown  that  a  tendency  to  a  reproduction  of  the 
dislocation  remains  for  some  time.  It  will  be  prudent  to  continue 
these  measures  of  protection  for  at  least  one  week ;  after  which  the 
danger  of  anchylosis  should  be  borne  in  mind,  and  the  extent  of 
passive  motion  should  be  gradually  and  cautiously  increased.  In  illus- 
tration of  this  tendency  to  reluxation,  Malgaigne  refers  to  the  case 
mentioned  by  Putegnat  of  a  woman  whose  jaw  for  many  years  became 
Aixated  at  least  once  a  month ;  but  she  was  always  able  to  reduce  it 
lerself. 


500  DISLOCATIONS    OF    THE    LOWEE    JAW. 


§  2.  Single,  or  Unilateral  Dislocations  . 

The  causes  of  this  accident  are  in  general  the  same  as  those  which 
produce  double  dislocations,  and  it  occurs  most  often  in  middle  life. 
Tartra  has  seen  one  exceptional  example  in  a  child  only  fifteen  months 
old,  and  Levison  saw  a  case  in  an  old  man  who  had  lost  all  his  teeth.^ 

Symptoms. — The  mouth  is  open,  but  not  so  widely  as  in  double  dis- 
location ;  the  jaw  is  nearly  immovable ;  the  teeth  are  advanced  ;  the 
condyloid  process  can  be  felt  in  front  of  the  articular  eminence,  leaving 
a  depression  in  its  natural  situation,  and  the  coronoid  process  is  more 
prominent  than  in  the  bilateral  dislocation. 

It  will  be  remembered  that  we  have  already  pointed  out  an  import- 
ant diagnostic  mark  between  a  fracture  of  the  neck  of  the  vertical 
ramus  and  a  dislocation  of  one  condyle.  In  the  latter  the  chin  in- 
clines to  the  opposite  side,  while  in  the  former  it  falls  toward  the  side 
upon  which  the  accident  has  occurred.  According  to  Hey,  this  lateral 
deviation  of  the  chin  is  not  always  present  in  dislocations ;  and  Robert 
Smith  mentions  one  case  in  which  the  surgeon  was  misled  by  this  cir- 
cumstance so  far  as  to  attempt  a  reduction  upon  the  left  side  when  the 
dislocation  was  upon  the  right. 

Treatment. — The  same  rules  of  treatment  which  we  have  established 
for  dislocations  of  both  condyles  will  be  applicable  to  the  single  dislo- 
cations, with  only  such  modifications  as  will  be  naturally  suggested  to 
the  surgeon. 

In  the  case  mentioned  by  Levison,  the  dislocation  was  constantly 
recurring  upon  the  left  side ;  and  it  was  especially  liable  to  happen 
when  just  awaking  from  sleep.  "He  would  then  pull  his  jaw,  press 
it  backwards,  when,  after  about  half  an  hour's  work,  bang  it  seemed 
to  go,  and  all  was  right  again."  This  old  gentleman  was  finally 
relieved  of  these  annoyances  by  a  band  fastened  under  the  chin.  In 
such  a  case,  an  apparatus  constructed  after  the  same  plan  as  my  lower 
jaw  fracture  apparatus  might  perhaps  serve  a  useful  purpose. 


§  3.  Conditions  of  the  Jaw  simulating  Luxations. 

There  is  a  condition  of  the  temporo-maxillary  articulation  called  by 
Sir  Astley  Cooper  "subluxation  of  the  jaw,"  in  which  it  is  assumed 
that  the  condyles  slip  before  the  anterior  margins  of  the  inter-articular 
cartilages,  and  thus  for  the  time  render  the  jaw  immovable.  No 
positive  evidence,  however,  has  ever  been  presented,  either  by  Sir 
Astley  or  others,  that  any  such  derangement  of  the  joint  apparatus 
does  actually  take  place,  the  opinion  being  based,  not  upon  dissections, 
but  only  upon  the  symptoms  which  are  known  to  accompany  the  acci- 
dent. It  is  quite  probable  that  this  explanation  of  the  phenomenon 
in  question  is  the  true  one,  yet  it  is  not  impossible  that  it  has  no 

*  Levison,  Boston  Med.  and  Surg.  Journ.,  voL  xxxiv.,  1846,  p.  388,  from  London 
Lancet. 


CONDITIONS    OF    THE    JAW    SIMULATING    LUXATIONS,     501 

relation  whatever  to  the  inter-articular  cartilages,  but  that  it  indicates 
a  true  subluxation  of  the  inferior  maxilla  upon  the  zygomatic  emi- 
nences. 

It  occurs  mostly  in  young  people,  and  in  those  of  a  feeble  or  scro- 
fulous diathesis.  Eelaxation  of  the  capsule,  ligaments,  and  muscles 
about  the  joint  may,  therefore,  be  regarded  as  the  principal  predispos- 
ing causes.  The  exciting  causes  are  generally  yawning  or  biting  upon 
some  very  hard  substance. 

The  symptoms  are  a  sudden  arrest  of  the  motions  of  the  jaw,  with 
the  mouth  about  half  open,  the  arrest  of  motion  being  accompanied  or 
preceded  generally  with  a  sensation  of  slipping  in  one  of  the  articula- 
tions. The  chin  is  slightly  inclined  to  the  opposite  side.  The  condyle 
may  be  felt  somewhat  advanced  in  its  socket,  and  while  it  remains  in 
this  position  the  patient  experiences  some  pain. 

Frequently  the  condyle  resumes  its  place  spontaneously,  or  after  a 
slight  lateral  motion  of  the  jaw ;  but  at  other  times  it  requires  some 
little  manual  force  to  replace  it, 

I  have  myself,  during  several  years  of  my  early  life,  while  pursuing 
my  studies  at  college,  experienced  this  accident  many  times.  It  was 
peculiarly  prone  to  occur  in  the  morning,  and  it  became  necessary 
that  I  should  eat  with  some  care  at  my  first  meal.  Sometimes  the 
locking  of  the  jaw  was  upon  the  right  and  sometimes  upon  the  left  side; 
it  was  always  painful.  Generally  the  condyle  was  made  to  fall  into 
place  by  a  voluntary  lateral  motion  of  the  jaw,  but  occasionally  I  was 
obliged  to  press  gently  against  the  chin  with  my  hand.  I  never 
adopted  any  measures  to  remove  the  predisposition,  but  as  I  became 
older  the  annoyance  gradually  ceased. 

Benevoli,  in  a  dissertation  published  at  Florence,  Italy,  in  the  year 
1747,  describes  another  condition  very  analogous  to  this  which  we 
have  now  described,  but  which  evidently  depended  upon  a  contraction 
of  the  muscles.  A  priest  having  opened  his  mouth  very  widely  in 
gaping,  found  himself  unable  to  close  it.  A  surgeon  who  was  called 
diagnosticated  a  dislocation  of  the  jaw,  and  attempted  to  reduce  it,  but 
failing,  Benevoli  was  called,  who,  observing  "  that  the  jaw  was  not 
absolutely  immovable,  that  the  articulations  were  not  separated,  and 
that  the  chin  did  not  incline  outwards  or  toward  the  sternum,"  con- 
cluded that  it  was  only  a  contraction  of  the  depressing  muscles.  He 
therefore  prescribed  fomentations  and  oily  unctions.  The  same  night 
the  temporal  muscles  had  acquired  the  size  of  a  couple  of  eggs,  from 
contraction,  but  the  next  day  the« patient  could  shut  his  mouth,  and 
by  the  following  day  the  tumefaction  of  the  temporal  muscles  had  also 
disappeared,  and  the  restoration  of  the  functions  of  the  mouth  was 
complete, 

Malgaigne,  to  whom  I  am  indebted  for  the  above  case,  relates  two 
others,  one  in  the  person  of  the  surgeon  Mothe,  and  the  other  in  a 
young  man  who  was  suffering  from  paralysis  and  spasmodic  contrac- 
tions of  the  muscles.  Mothe  observes  that  it  had  occurred  to  him 
very  often,  and  that  it  still  continued  to  happen  sometimes,  that  when 
he  gaped  pretty  widely,  the  genio-hyoid  and  mylo-hyoid  muscles  con- 
tracted with  so  much  force  as  to  render  it  impossible  for  him  to  close 


502  DISLOCATIONS    OF    THE    SPINE. 

his  mouth ;  these  muscles  being  thus  in  a  state  of  cramp,  their  bellies 
became  hard  under  the  chin,  and  so  painful  that  he  was  obliged  imme- 
diately to  press  upwards  against  the  under  surface  of  the  chin  in  order 
to  oppose  their  action.  This  condition  would  last  from  one  to  three 
minutes,  and  was  relieved,  generally,  by  frictions  made  with  the  hand 
over  the  contracted  muscles.  Sometimes  he  actually  believed  that 
the  lower  jaw  was  dislocated,  although  the  result  always  convinced 
him  that  it  was  not. 


CHAPTER    III. 

DISLOCATIONS    OF   THE    SPINE. 

Delpech  and  Abernethy  denied  the  possibility  of  a  dislocation  of 
the  spine,  either  in  the  cervical,  dorsal,  or  lumbar  region,  without  the 
concurrence  of  a  fracture. 

Says  Sir  Astley  Cooper :  "  I  have  never  witnessed  a  separation  of 
one  vertebra  from  another  through  the  inter- vertebral  substance,  with- 
out fracture  of  the  articular  processes ;  or,  if  those  processes  remain 
unbroken,  without  a  fracture  through  the  bodies  of  the  vertebrae." 
He  would  not,  however,  be  understood  to  deny  the  possibility  of  a 
dislocation  of  the  cervical  vertebrae,  their  articular  processes  being 
placed  more  obliquely  than  those  of  the  other  vertebrae. 

The  accident  is,  no  doubt,  exceedingly  rare,  at  least  without  the 
complication  of  a  fracture,  and  it  is  not  improbable  that  the  actual 
number  is  smaller  than  the  reported  examples  would  indicate.  Those 
who  make  autopsies  do  not  always  perform  their  duties  with  that 
exact  fidelity  which  might  be  necessary  to  determine  so  nice  a  point 
as  a  fracture  of  an  oblique  process,  and  it  is  quite  likely  that  the  cir- 
cumstance may  have  been  overlooked  in  some  cases;  but  a  consider- 
able number  of  well  authenticated  examples  of  simple  dislocations  of 
cervical  vertebra  have  accumulated  within  the  last  fifty  years.  The 
reported  examples  of  simple  dislocations  of  the  other  vertebrae  are  not 
so  numerous,  nor  as  well  attested. 

The  causes  are  in  general  the  same  with  those  which  produce  frac- 
tures of  the  vertebrae,  such  as  falls  upon  the  head,  feet,  or  back,  and 
violent  flexions  of  the  spine  backwards  or  to  the  one  side  or  the  other. 

Several  examples  are  recorded  of  "  spontaneous"  dislocations,  the 
result  of  some  morbid  changes  in  the  bones  or  in  the  ligaments  of  the 
spinal  column;  which  accidents  seem  to  belong  more  properly  to 
general  treatises  upon  surgery. 

The  symptoms,  also,  partake  of  the  same  general  character  with 
fractures;  the  accident  being  accompanied  with  more  or  less  complete 
paralysis  of  those  portions  of  the  body  which  receive  their  nervous 


DISLOCATIONS    OF    THE    LUilBAK    YEETEBE^.  503 

supply  from  below  tlie  point  at  which  the  dislocation  has  occurred  ; 
the  spinal  column  presenting  at  the  seat  of  displacement  an  angular 
projection  or  some  form  of  irregularity ;  and  the  distortion  being 
attended  with  pain,  especially  when  an  attempt  is  made  to  move  the 
body. 

In  very  many  cases  the  symptoms  are  so  nearly  like  those  presented 
in  a  case  of  fracture,  that  the  diagnosis  is  rendered  exceedingly  difficult. 
The  presence  or  absence  of  crepitus  may  aid  in  the  diagnosis,  and  yet 
it  is  well  understood  that  this  symptom  is  often  absent  in  simple  frac- 
tures, and  that  it  may  be  present  in  all  those  examples  of  dislocation 
which  are  accompanied  with  a  fracture  of  an  oblique  process,  or  of 
any  other  portion  of  the  vertebra,  which  class  of  examples  constitutes 
a  large  majority  of  the  whole  number. 

There  is  usually  present  however,  in  the  dislocation,  whether  partial 
or  complete,  a  peculiar  fixedness  or  rigidity  of  the  spine,  which  serves 
to  distinguish  this  accident  from  a  fracture  of  the  spine  as  plainly  as 
the  preternatural  rigidity  of  the  limb  in  dislocations  of  the  long  bones 
serves  to  distinguish  these  accidents  from  fractures  of  the  same  bones. 
The  head,  or  upper  portion  of  the  spinal  column  is  bent  forwards,  or 
backwards,  or  more  commonly  to  one  side,  and  in  this  position  it 
remains  immovably  fixed  until  the  reduction  is  accomplished.  Some- 
times, also,  the  surgeon  may  feel  distinctly  the  lateral  deviation  of 
the  spinous  process,  and,  in  the  neck,  the  transverse  processes  become 
an  important  guide  in  the  diagnosis. 

After  these  few  general  remarks,  I  shall  proceed  to  speak  of  disloca- 
tions of  the  spine  in  the  same  order  in  which  I  have  treated  of  fractures 
of  the  spine. 


§  1 .    DiSLOCATIOXS  OF  THE  LUMBAR  TeRTEBR^. 

Sir  Astley  Cooper  plainly  intimates  that  he  does  not  believe  a  dis- 
location can  occur  in  either  the  dorsal  or  lumbar  region  without  the 
concurrence  of  a  fracture,  and  Boyer  affirms  positively  that  it  is 
''entirely  impossible." 

AYithout  wishing  ourselves  to  insist  upon  the  actual  impossibility 
of  these  accidents,  we  are  prepared  to  affirm  that  no  well-authenticated 
case  has  yet  been  reported ;  at  least  of  a  complete  dislocation,  unac- 
companied with  a  fracture  of  the  articulating  apophyses.  We  can 
even  conceive  it  possible  that  a  lumbar  vertebra  may  be  dislocated 
forwards  or  backwards,  and  that  a  dorsal  vertebra  may  be  dislocated 
laterally,  without  a  fracture;  yet  we  hardly  think  either  of  these  events 
probable.  TThat  we  urge,  however,  is  that  no  evidence  appears  to  be 
furnished  that  such  a  dislocation  has  actually  occurred. 

Cloquet  mentions  the  case  of  a  "  tiler"  who  fell  from  the  roof  of  a 
house  backwards,  and  dislocated  one  of  the  lumbar  vertebras.  This 
patient  lived  many  years  after  the  accident,  and  at  the  autopsy  it  was 
found  that  the  second  lumbar  vertebra  had  been  luxated  to  the  right 
by  a  movement  of  rotation  about  the  left  articular  process,  the  two 
oblique  processes  of  the  left  side  preserving  their  connection,  while 


504  DISLOCATIONS    OF    THE    SPINE, 

those  of  the  riglat  were  separated  quite  half  an  inch.  The  right  verte- 
bral phite  was  broken,  and  the  canal  of  the  vertebra  was  thus  thrown 
open  and  widened.' 

Dupuytren  says  that  a  man  was  crushed  by  the  falling  of  a  bank  of 
earth  upon  his  loins,  when  in  the  act  of  bending  forwards.  On  the 
third  day  he  was  brought  to  Hotel  Dieu,  when  it  was  observed  that 
his  lower  extremities  were  completely  paralyzed,  and  that  there  existed 
in  the  upper  part  of  the  lumbar  region,  a  hard  tumor,  by  pressure  upon 
which  a  crepitus  was  manifest.  A  second  tumor  could  be  distinctly 
felt  in  front  through  the  abdominal  parietes,  and  the  length  of  the 
spine  was  evidently  diminished.  This  man  died  on  the  sixth  day  from 
a  gradual  asphyxia.  When  the  body  was  examined  it  was  found  that 
the  last  dorsal  and  first  lumbar  vertebrse  had  been  pushed  forwards 
more  than  one  inch,  lacerating  the  spinal  marrow,  breaking  the  trans- 
verse and  oblique  processes  of  the  last  dorsal  and  first  two  lumbar 
vertebrge,  and  tearing  off  a  small  fragment  of  the  body  of  one  of  the 
vertebrse  where  the  intervertebral  substance  adhered  to  it.^ 

These  are  all  the  cases  of  dislocation  of  the  lumbar  vertebrse  of 
which  I  am  able  to  find  any  record.  Both  were  accompanied  with 
fractures.  In  neither  case  was  any  attempt  made  to  reduce  the  dis- 
locations. In  the  second,  it  is  scarcely  probable  that  any  means  could 
have  been  employed  which  would  have  succeeded  in  restoring  the 
bones  to  their  places;  nor  is  it  probable  that  if  the  bones  had  been 
restored  to  place,  the  patient  would  have  survived  the  accident  a 
day  longer,  probably  not  so  long.  The  cord  was  greatly  lacerated, 
and  the  diaphragm  torn  up  and  displaced,  rendering  a  recovery  almost 
impossible. 

In  the  first  example,  where  the  dislocation  was  less  complete,  and  the 
complications  less  grave,  could  reduction  have  offered  any  reasonable 
chance  for  relief?  By  extension,  combined  with  a  movement  of  rota- 
tion in  a  direction  opposite  to  that  in  which  the  displacement  had  taken 
place,  it  is  possible  that  a  reduction  might  have  been  accomplished. 
The  attempt  certainly  would  have  been  justifiable;  but  since  the  man 
lived  "  many  years"  without  the  reduction,  it  is  doubtful  whether  the 
result  of  a  reduction  would  have  been  more  fortunate. 


§  2.  Dislocations  op  the  Dorsal  Yertebr^. 

Malgaigne  enumerates  twelve  examples  of  dislocations  of  the  dorsal 
vertebra.  I  have  found  reported  by  American  surgeons,  at  dates  too 
recent  to  have  been  included  in  his  analysis,  two  other  examples ;  but 
of  this  number  only  three  are  claimed  to  have  been  simple  dislocations, 
unaccompanied  with  fracture.  One  of  the  fourteen  was  a  dislocation  of 
the  fifth  dorsal  vertebra  upon  the  sixth,  one  of  the  eighth,  two  of  the 
ninth,  five  of  the  eleventh,  and  five  of  the  twelfth.  The  relative  fre- 
quency of  their  occurrence  in  the  different  vertebrse  corresponding 

'  Cloquet,  Malgaigne,  from  Journ.  des  Diflformites  de  Maisonabe,  torn.  i.  p.  453. 
2  Dupuytren,  Injuries  and  Dis.  of  Bones,  Syd.  ed.,  p.  340, 


DISLOCATIONS    OF    THE    DORSAL    VERTEBRAE.  505 

with  the  observation  of  Weber,  as  to  the  points  of  the  spinal  marrow 
which  allow  of  the  greatest  freedom  of  motion,  and  are  consequently 
most  liable  to  dislocations.  The  direction  of  the  displacement  in  ten 
cases,  was  observed  to  be  six  times  forwards,  twice  backwards,  and 
twice  to  the  one  side. 

Two  of  those  which  were  unaccompanied  with  fracture,  occurring 
respectively  in  the  tenth  and  sixth  dorsal  vertebra,  were  examples  of 
a  dislocation  forwards,  and  the  third,  belonging  to  the  ninth  vertebra, 
was  a  dislocation  backwards.  A  lateral  luxation  v/ithout  fracture  has 
not  been  recorded.  It  is  worthy  of  remark,  also,  that  these  three  ex- 
amples, being  all  which  our  science  up  to  this  moment  possesses,  have 
happened  in  the  experience  of  the  same  surgeon.^ 

A  moment's  consideration  of  the  anatomy  of  these  processes  will 
render  it  apparent  that  even  a  partial  luxation  forwards  without  a  frac- 
ture of  the  oblique  apophyses  is  impossible,  and  that  in  the  direction 
backwards,  the  luxation  can  only  occur  to  the  extent  of  about  one- 
quarter  of  an  inch,  constituting  only  a  species  of  articular  diastasis, 
without  breaking  off  the  articulating  apophyses  of  the  lower  corres- 
ponding vertebra.  The  first  two  examples,  therefore,  notwithstanding 
they  have  been  received  without  question  by  Malgaigne,  I  shall  un- 
hesitatingly reject.  The  third,  which  alone  carries  evidence  of  its 
having  been  correctly  reported,  and  which  was  only  a  partial  disloca- 
tion, is  related  as  follows:  "A  mason  having  fallen  from  a  height  in 
such  a  manner  as  that  the  lower  part  of  his  back  struck  upon  the 
angle  of  the  upper  step  of  a  ladder,  died  on  the  following  day.  After 
death  it  was  observed  that  the  spinous  processes  of  the  dorsal  vertebrae 
were  prominent  down  to  the  tenth  ;  and  that  the  tenth  process  with  all 
of  the  processes  below  were  depressed.  It  was  also  noticed  that  this 
depression,  very  marked  when  the  trunk  was  thrown  backwards, 
gradually  diminished  and  finally  disappeared  altogether  when  the  body 
was  bent  forwards.  On  removing  the  soft  parts  it  was  found  that  the 
ligaments  were  extensively  torn  asunder  and  detached,  so  as  to  permit 
the  articulating  apophyses  of  the  tenth  vertebra  to  be  carried  into 
contact  with  the  back  of  the  ninth.  The  spinal  marrow  had  under- 
gone no  visible  alteration.^ 

Malgaigne  thinks  he  has  once  observed  the  same  thing  on  a  living 
subject,  and  that  by  simply  bending  the  body  forwai'ds  he  accom- 
plished the  reduction  and  effected  a  perfect  cure,  except  that  a  slight 
curvature  remained  at  the  point  of  injury. 

Among  the  cases  reported  as  having  been  complicated  with  fracture, 
the  following  example,  reported  by  Dr.  Graves,  of  New  Hampshire,  to 
Dr.  Parker,  of  New  York,  possesses  unusual  interest. 

On  the  second  day  of  Jan.  1852,  a  man,  set.  25,  was  struck  on  the 
back  while  in  a  stooping  posture  by  a  falling  mass  of  timber,  causing 
a  dislocation  of  the  last  dorsal  upon  the  first  lumbar  vertebra.  His 
lower  extremities  were  completely  paralyzed,  and  priapism  continued 
for  several  hours.  The  surgeon  determined  to  make  an  attempt  at  re- 
duction, and  for  this  purpose  he  placed  the  patient  upon  his  face,  and 

■  Melcliiori,  Gaz,  Medica,  stati  sardi,  1850,  ^  Melehiori,  loc,  cit. 


506  DISLOCATIONS    OF    THE    SPINE. 

secured  a  folded  sheet  under  his  armpits  and  another  around  his  hips, 
directing  four  strong  men  to  make  extension  and  counter-extension  by 
these  sheets.  Chloroform  was  administered,  and  when  the  patient  was 
completely  under  its  influence,  the  extending  and  counter-extending 
forces  were  applied,  and  in  a  few  minutes  the  vertebrae  glided  into 
place  with  a  distinct  bony  crepitus.  The  restoration  of  the  line  of 
the  vertebral  column  was  found  to  be  nearly  but  not  quite  perfect. 

On  the  sixteenth  day  he  began  to  have  slight  sensations  in  his  feet, 
and  at  the  end  of  six  or  eight  weeks  he  was  able  to  control  the  evacua- 
tions from  the  bladder  and  rectum.  Several  months  later  he  had  re- 
covered so  completely  as  to  walk  with  only  the  aid  of  a  cane.-' 

I  know  of  only  one  similar  case.  Eudiger  has  published  an  account 
of  a  dislocation  obliquely  backwards  and  to  the  right  side,  which 
occurred  at  the  same  point  in  the  spinal  column.  The  subject  was  a 
musketeer,  who  had  been  struck  upon  his  back  by  a  falling  wall 
which  he  was  endeavoring  to  pull  down.  Rudiger  laid  him  upon 
his  belly,  and  by  the  assistance  of  others  he  was  able,  but  not  with- 
out causing  pain,  to  reduce  the  bones.  Immediately,  however,  when 
the  extension  was  discontinued,  the  action  of  the  muscles  caused  the 
displacement  to  recur.  The  surgeon  then  directed  four  men  to  make 
extension,  while  another  man  retained  the  bones  in  place  by  pressing 
upon  them  with  his  hands.  After  several  hours  this  method  of  pres- 
sure was  replaced  by  a  board  underlaid  with  compresses  and  sustain- 
ing a  weight  of  more  than  fifty  livres.  On  the  following  day  it  was 
found  sufficient  to  bind  compresses  over  the  projecting  bone,  and  in 
this  condition  the  patient  remained  fifteen  days ;  during  all  of  which 
time  he  lay  upon  his  belly  with  his  shoulders  more  elevated  than  his 
pelvis.  On  the  twentieth  day  he  could  lie  upon  his  back,  and  in 
about  six  weeks  he  was  so  completely  restored  as  to  be  able  to  pursue 
his  trade  as  before  P  This  is  certainly  a  very  extraordinary  case, 
whether  considered  in  reference  to  the  means  employed  to  restore  the 
bones  to  place,  or  to  its  results :  and  if  the  statements  are  to  be  re- 
ceived at  all,  it  must  be  with  some  hesitation  and  allowance. 

On  the  other  hand,  we  are  able  to  present  at  least  one  example  in 
which,  although  no  reduction  has  been  accomplished,  the  patient  has 
survived  the  accident  many  years;  yet  it  must  be  admitted  that  his 
recovery  is  far  from  having  been  as  conjplete  as  in  the  two  cases  just 
mentioned. 

Joseph  Stocks,  set.  11,  in  the  spring  of  1826,  was  crushed  under  the 
body  of  an  ox-cart  in  such  a  manner  as  to  produce  a  dislocation  of 
the  last  dorsal  from  the  first  lumbar  vertebra,  causing  immediately 
almost  com^plete  paralysis  of  all  the  parts  below.  This  young  man 
was  seen  by  Dr.  Swan,  of  Springfield,  Mass.,  in  the  summer  of  1834,  at 
which  time  he  was  occupied  as  a  portrait  painter.  His  lower  extremi- 
ties remained  paralyzed  and  of  the  same  size  as  at  the  time  of  the 
receipt  of  the  injury.  He  was  unable  to  sit  erect  owing  to  the  mobility 
of  the  spine  at  the  seat  of  dislocation,  and  he  had  therefore  lain  con- 

1  Graves,  N.  Y.  Journ.  Med.,  March,  1852,  p.  190. 

2  Rudiger,  Jouru..de  Chir.  de  Desault,  torn.  iii.  p.  59. 


DISLOCATIONS    OF    SIX    LOWEE    CERVICAL    VERTEBRA.      507 

stantly  upon  his  side.  The  upper  portion  of  his  body  was  well  de- 
veloped, and  his  intellectual  faculties  were  of  a  high  order ,^ 

It  is  not,  however,  with  a  life  of  perpetual  deformity  that  the  two 
examples  of  reduction  already  described  are  to  be  contrasted.  A  result 
so  fortunate  as  this,  where  the  bones  remain  unreduced,  is  unique;  in 
all  the  other  cases  reported  the  patients  died  miserably  after  periods 
ranging  from  a  few  days  to  one  year  or  a  little  more. 

Charles  Bell  has  related  the  case  of  an  infant  who  was  run  over  by 
a  diligence,  and  who  died  thirteen  months  after  the  accident.  On  ex- 
amination after  death  the  last  dorsal  vertebra  was  found  to  be  com- 
pletely luxated  backwards  and  to  the  left,  upon  the  first  lambar 
vertebra.^ 

With  these  facts  before  us,  I  think  we  cannot  hesitate  when  the 
nature  of  the  accident  is  fully  made  out,  and  especially  when  the  dis- 
location has  occurred  in  the  lower  dorsal  vertebrae,  to  attempt  the 
reduction  by  forcible  extension,  united  with  judicious  lateral  motion, 
or  with  a  certain  amount  of  direct  pressure  upon  the  projecting 
spines. 


§  3.  Dislocations  of  the  Six  Lower  Cervical  Yertebr.^. 

It  is  much  more  common  to  meet  with  simple  luxations  of  the  ver- 
tebra of  the  neck  uncomplicated  with  fractures,  than  of  either  of  the 
other  vertebral  divisions.  This  is  doubtless  owing  to  the  greater 
extent  of  motion  which  their  articulating  surfaces  enjoy. 

They  may  be  dislocated  forwards  or  backwards.  The  forward  lux- 
ation may  be  complete  or  incomplete;  with  both  sides  equally  advanced 
("bilateral"  of  Malgaigne),  or  one  of  the  articulating  apophyses  may  be 
dislocated  forwards,  leaving  the  opposite  apophysis  in  its  place  ("uni- 
lateral" of  Malgaigne). 

Schranth^  has  collected  twenty-four  examples  of  luxation  of  the 
cervical  vertebrae,  of  which  four  are  recorded  as  dislocations  forwards, 
two  back,  and  six  to  the  one  side  or  the  other.  Three  of  this  number 
were  dislocations  of  the  atlas;  two  were  dislocations  of  the  second 
vertebra ;  five  of  the  fourth ;  two  of  the  fifth  ;  two  of  the  sixth,  and 
one  of  the  seventh.     In  the  other  cases  the  seat  was  not  stated. 

Malgaigne  has  brought  together  forty-five  examples;  of  which 
twenty-one  were  complete  forward  luxations,  nine  incomplete  forward 
luxations,  nine  unilateral  and  forwards,  and  four  were  backward 
luxations.  Three  were  dislocations  of  the  second  vertebra  upon  the 
third,  four  were  dislocations  of  the  third  vertebra,  ten  of  the  fourth, 
eleven  of  the  fifth,  fifteen  of  the  sixth,  and  two  of  the  seventh. 

The  bilateral  forward  luxations  are  generally  caused  by  a  fall  upon 
the  top  and  back  of  the  head,  or  upon  the  top  of  the  head  while  the 
neck  is  very  much  flexed  forwards.  The  unilateral  is  caused  gene- 
rally by  a  direct  blow  upon  the  back  of  the  neck,  the  blow  being 

1  Swan,  Bost.  Med.  and  Surg.  Journ.,  vol.  :xxii.  p.  102,  March,  1840. 

^  Charles  Bell,  on  Injuries  of  the  Spine.  1824. 

'  Schranth,  Amer.  Journ.  Med.  Sci.,  May,  1848,  from  Archiv.  for  Phys.     Heilkunde. 


508  DISLOCATIONS    OF    THE    SPINE. 

probably  directed  somewhat  to  one  side  or  the  other.  The  number  of 
backward  luxations  which  have  been  reported  are  too  few  to  enable 
us  to  indicate  very  accurately  the  general  causes,  but  it  seems  proba- 
ble that  they  are  most  often  occasioned  by  a  fall  upon  the  fore  and  top 
part  of  the  head,  received  while  the  neck  is  bent  forcibly  back. 

In  dislocations  of  the  cervical  vertebrae  forwards,  the  head  is  usually 
depressed  toward  the  sternum;  in  dislocations  backwards  the  head  is 
thrown  back,  and  in  unilateral  dislocations  the  head  is  turned  over 
one  of  the  shoulders.  Neither  of  these  malpositions  of  the  head  is 
uniformly  present  in  these  several  dislocations,  and  indeed  not  un- 
frequently,  especially  in  case  the  system  is  greatly  shocked  by  the 
accident,  the  head  and  neck  assume  a  preternatural  mobility,  and  may 
be  turned  easily  in  any  direction. 

The  spinous  process,  unless  the  patient  is  very  fleshy  or  considera- 
ble swelling  has  supervened,  can  easily  be  felt,  and  its  deviations  to 
the  right  or  to  the  left,  forwards  or  backwards,  furnish  us  with  the 
most  valuable  and  important  sign  of  the  dislocation.  Even  the  trans- 
verse processes  may  be  felt  sometimes,  especially  in  the  upper  part  of 
the  neck,  with  sufficient  distinctness  to  render  them  useful  in  the 
diagnosis. 

To  these  circumstances  we  may  add  paralysis  of  the  body  below  the 
seat  of  injury,  with  pain  and  swelling  at  the  point  of  dislocation.  In 
some  cases  also  the  patient  has  himself  distinctly  felt  a  cracking  or 
sudden  giving  way  in  the  neck  at  the  moment  of  the  accident. 

Prognosis. — The  complete  bilateral  luxations,  whether  backwards  or 
forwards,  have  in  most  cases  terminated  fatally  within  a  short  time, 
generally  within  forty-eight  hours.  Unilateral  luxations  are  less 
speedy  in  their  results,  but  when  the  dislocation  remains  unreduced, 
death  generally  takes  place  in  a  month  or  two.  Lente,  of  New  York, 
relates  a  case  of  incomplete  dislocation  of  the  fifth  cervical  vertebra 
backwards,  unaccompanied  with  fracture,  which  accident  the  patient 
survived  five  days.^  A  patient  of  Roux's  lived  eight  days;  but  in 
the  case  of  a  second  patient  mentioned  by  Lente,  with  a  complete 
luxation,  without  fracture,  of  the  fifth  vertebra,  the  patient  survived 
the  injury  only  two  hours.^ 

On  the  other  hand,  occasional  examples  are  presented  of  partial  or 
complete  recovery  with  the  luxation  unreduced. 

Horner,  of  Philadelphia,  presented  to  the  class  of  medical  students 
of  the  University  of  Pennsylvania  in  1842,  a  lad  £et.  10,  who  had  fallen 
a  distance  of  twenty  feet,  alighting  upon  his  head.  He  was  found 
senseless  and  motionless,  with  his  head  bent  under  his  body.  He 
gradually  recovered  from  the  shock,  but  his  neck  was  stiff,  distorted, 
and  motionless,  his  face  being  inclined  downwards  to  the  right  side. 
Two  days  after,  his  "common  and  accurate  perceptions  returned,  but 
he  was  affected  for  some  time  with  tingling  and  numbness  in  his  left 
arm."  When  presented  to  the  class  the  transverse  processes,  from  the 
fifth  upwards,  were  about  half  an  inch  in  front  of  those  below,  showing 
that  the  left  oblique  process  of  the  fourth  was  dislocated  forwards 

•  Lente,  New  York  Journ.  Med.,  May,  1850,  p.  284.  ^  Lente,  ibid.,  p.  397. 


DISLOCATIONS    OF    SIX    LOWER    CERVICAL    VERTEBRA.      509 

upon  the  fifth.  The  rotar_y  motions  of  the  neck  could  now  be  exe- 
cuted to  some  extent,  but  much  more  freely  to  the  right  than  to  the 
left.  Professor  Horner  refused  to  make  any  attempt  to  reduce  the 
dislocation,^ 

Dr.  Purple,  of  New  York,  has  reported  a  case  of  what  was  called  a 
dislocation  of  the  fifth  and  sixth  cervical  vertebrae,  producing  complete 
paralysis  of  the  lower  part  of  the  body,  in  which  the  patient  survived 
the  accident  many  years ;  but  his  lower  extremities  were  so  useless 
and  cumbersome  as  to  induce  him,  in  the  year  1851,  six  years  after 
the  injury  had  been  received,  to  submit  to  the  amputation  of  both  at 
the  hip-joint.  In  1852,  having  become  very  intemperate,  he  died,  but 
no  autopsy  was  obtained,  so  that  the  exact  character  of  the  injury  was 
never  ascertained.^  Sanson,  of  Paris,  has  reported  also  a  case  which 
came  under  his  observation  at  Hotel-Dieu,  of  dislocation  of  the  "third 
cervical  vertebra  backwards,"  from  which,  although  unreduced,  the 
patient  partially  recovered.  The  character  of  this  accident  was  not 
much  better  determined ;  for,  although  he  felt  a  severe  and  sharp  pain 
at  the  moment  of  the  injury,  which  was  greatly  aggravated  by 
motion,  and  his  head  was  bent  forwards  and  to  the  left,  "the  chin 
being  fixed  on  the  upper  part  of  the  sternum,"  there  was  no  paralysis 
of  either  the  motor  or  sentient  nerves.  After  the  lapse  of  about  four 
months  he  left  the  hospital,  still  unable  to  lift  his  chin  more  than  four 
inches  from  the  sternum;  after  which  he  resumed  his  usual  occupa- 
tions, suffering  no  further  inconvenience  than  what  was  occasioned 
by  the  unnatural  position  of  his  head.^  Notwithstanding  the  authori- 
tative testimony  of  Sanson  that  this  was  a  dislocation  backwards,  one 
cannot  avoid  the  conclusion  that  it  was  either  a  unilateral  subluxa- 
tion, or  perhaps  a  mere  diastasis  of  the  articulation,  or  else  that  it  was 
an  example  of  sprain  of  the  muscles,  and  consequent  contraction  of  one 
set,  or  paralysis  of  the  opposing  set  of  muscles.  It  is  certain  that  it 
was  not  a  complete  luxation,  nor,  since  there  was  no  paralysis  of  the 
bod}'  below  the  point  of  injury,  can  it  be  properly  made  use  of  as  an 
argument  for  non-interference  where  such  paralysis  does  actually  exist. 

Let  us  see  now  what  encouragement  an  attempt  at  reduction  may 
offer,  in  a  case  which  presents  so  little  ground  of  hope  where  the 
reduction  is  not  accomplished. 

Dr.  Spencer,  of  Ticonderoga,  N.  Y.,  relates  that  a  man,  set.  50,  fell 
backwards  from  a  board  fence,  striking  upon  the  superior  and  anterior 
portion  of  his  head,  dislocating  the  second  from  the  third  vertebra  of 
the  neck.  His  head  was  thrown  back  so  far  as  to  prevent  his  seeing 
his  own  body,  and  all  below  the  injury  was  completely  paralyzed. 
Kepeated  attempts  were  made  to  reduce  the  dislocation,  "but  the 
transverse  processes  had  become  so  interlocked  that  every  effort  proved 
abortive,"  and  he  died  forty-eight  hours  after  the  injury  was  received." 
Gaitskill  also  attempted  reduction  in  a  case  of  dislocation  of  the  seventh 

'  Horner,  Amer.  Journ.  Med.  Sci.,  April,  1843,  from  Med.  Exam. 

2  Purple,  New  York  Journ.  Med.,  May,  1853,  p.  319. 

^  Sanson,  Amer.  Journ.  Med.  Sci.,  Feb.  1836,  p.  514 ;  from  Gaz.  des  HopitauJ^. 

"  Spencer,  Boston  Med.  and  Surg.  Journ.,  vol.  x.  No.  11. 


510  DISLOCATIONS    OF    THE    SPIISTE. 

cervical  vertebra,  but  failed.^  Boyer  failed  in  two  cases.  It  is  related 
by  Petit  Eadel,  that  a  young  patient  at  La  Charite  expired  in  the 
hands  of  the  surgeons,  upon  such  an  attempt  being  made  a  few  days 
after  the  accident;^  and  Dupuytren  says  "the  reduction  of  these  dislo- 
cations is  very  dangerous,  and  we  have  often  known  an  individual 
perish  from  the  compression  or  elongation  of  the  spinal  marrow  which 
always  attends  these  attempts." 

Dr.  Shuck,  of  Vienna,  relates  that  a  man,  set.  24,  while  engaged  at 
his  work  on  the  fifth  of  Dec,  1838,  twisted  his  head  suddenly  round, 
in  consequence  of  one  of  his  companions  roaring  into  his  ear,  when  he 
instantly  felt  something  give  way  in  his  neck,  and  found  it  impossible 
to  move  his  head.  Next  morning  his  head  was  turned  to  the  right 
and  bent  down  toward  the  shoulder.  Every  attempt  to  move  his  head 
caused  great  pain.  He  complained  of  weakness  in  his  right  arm,  but 
all  the  other  functions  of  his  body  were  perfect.  An  attempt  was 
immediately  made  to  reduce  the  dislocation  by  lifting  him  by  the  head, 
but  without  success.  On  the  7th  of  Dec,  the  weakness  and  numbness 
of  the  right  arm  had  increased,  and  the  attempt  to  reduce  the  bones 
was  renewed.  The  patient  was  laid  horizontally  upon  a  bed,  and  ex- 
tension made  from  the  chin  and  occiput  while  counter-extension  was 
made  from  the  shoulders.  The  force  thus  employed  was  gradually 
increased  until  the  patient  and  assistant  felt  a  snap  as  of  two  bones 
meeting,  when  it  was  found  that  the  head  was  restored  to  its  natural 
position,  and  the  power  of  moving  it  had  returned.  The  next  day  his 
arm  was  more  powerless  than  before,  and  on  the  following  day  he  had 
vertigo,  but  these  symptoms  soon  yielded  to  copious  bleedings,  and  he 
left  the  hospital  cured  on  the  13th.^ 

Dr.  Hickerman,  of  Ohio,  has  reported  also  in  the  Ohio  Medical 
Journal^  a  case  of  dislocation  of  one  of  the  cervical  vertebra,  the 
original  account  of  which  I  have  not  seen,  but  only  an  abridged  state- 
ment published  in  the  Buffalo  Medical  Journal.  By  exploring  the 
pharynx  a  prominence  was  felt  opposite  the  junction  of  the  fourth  and 
fifth  cervical  vertebrse ;  and  the  action  of  the  heart  was  barely  per- 
ceptible. Seizing  the  patient's  head  under  his  left  arm.  Dr.  Hickerman 
in  this  manner  made  traction,  while  with  the  index  finger  of  the  right 
hand  in  the  patients  throat  he  made  firm  pressure  obliquely  upwards, 
backwards,  and  to  the  left;  after  continuing  the  pressure  for  about 
forty  or  fifty  seconds,  the  part  against  which  the  finger  was  placed 
gradually,  yet  quickly,  receded  in  the  direction  in  which  the  pressure 
was  made,  and  instantly,  as  quickly  indeed  as  the  act  could  be  possibly 
executed,  the  patient  opened  her  eyes,  and  natural  respiration  was 
established.  She  then  also  immediately  became  conscious  of  what  was 
transpiring  about  her,  and  signified  by  signs,  for  she  was  yet  unable 
to  speak,  that  she  had  suffered  pain  in  the  epigastrium.  Complete 
recovery  took  place." 

Schranth  received  under  his  care  a  patient  who  had  a  luxation  of 

1  Gaitskill,  London  Repository,  vol.  xv.  p.  282. 

2  pgtjt  Radel,  Note  to  Boyer  Malad.  Chir.,  vol.  v.  p.  118. 
^  Shuck,  Amer.  Journ.  Med.  Sci.,  July,  1841,  p.  207. 

*  Hickerman,  Buf.  Med.  Journ.,  vol.  x.  p.  702,  April,  1855. 


DISLOCATIONS    OF    SIX    LOWER    CERVICAL    VERTEBRA.      511 

the  "  right  transverse  apophysis"  of  the  fourth  cervical  vertebra, 
without  lesion  of  the  spinal  marrow,  which  he  reduced  on  the  seventh 
day.  The  first  attempt  was  unsuccessful;  but  the  second,  made  with 
great  caution,  by  the  aid  of  four  assistants,  three  of  whom  pulled 
the  head  upwards  while  the  fourth  pressed  with  his  whole  weight 
upon  the  shoulders,  was  completely  successful.  During  the  time  that 
the  traction  was  being  made,  the  head  was  occasionally  rotated  slightly 
and  moved  laterally,  and  at  the  same  moment  the  surgeon  pushed 
firmly  against  the  displaced  apophysis.  The  reduction  was  attended 
with  "  various  distinct  crackings  in  the  neck,"  which  were  loud  enough 
to  be  heard.  After  some  days  of  repose  he  resumed  his  occupation, 
no  stiffness  remaining  in  the  movements  of  his  neck.' 

Dr.  Edward  Maxson,  of  Geneva,  N.  Y.,  was  called  on  the  28th  of 
Oct.  1856,  to  see  a  child  about  nine  years  old,  who  had  met  Avith  a 
similar  accident  about  forty  hours  before,  namely,  a  dislocation  of  the 
right  articulating  apophysis  of  the  fifth  or  sixth  cervical  vertebra, 
occasioned  by  suddenly  turning  her  head  around  while  at  play.  She 
at  first  complained  only  of  pain  and  inability  to  straighten  the  neck ; 
but  whenever  moved  she  became  faint  and  irritable.  A  short  time 
before  the  surgeon  was  called  the  mother  had,  in  attempting  to  move 
her  in  bed,  turned  the  face  a  little  more  to  the  left,  when  a  severe 
convulsion  immediately  ensued.  On  examining  the  neck  Dr.  Maxson 
discovered  the  displacement  of  the  transverse  process.  Having  ad- 
vised the  parents  of  the  danger  necessarily  incident  to  an  attempt  at 
replacement,  and  of  the  probable  consequences  of  its  being  permitted 
to  remain  as  it  was,  they  consented  that  the  trial  should  be  made.  "I 
grasped  the  head,"  says  Dr.  M.,  "  with  both  hands,  and  proceeded 
according  to  Desault's  method,  only  I  first  carried  or  turned  the  face 
very  gently  a  little  further  toward  the  left  shoulder,  to,  if  possible, 
disengage  the  process ;  then  lifting  or  extending  the  head,  I  turned 
the  face  very  gently  toward  the  right  shoulder,  when  the  difficulty 
was  at  once  overcome,  and  she  exclaimed:  'I  can  move  my  eyes.' 
Her  countenance  soon  acquired  a  more  natural  appearance ;  the  faint- 
ness  passed  off;  she  rested  quietly  through  the  night ;  had  no  return 
of  the  difiiculty,  and  needed  only  an  emollient  anodyne  to  soothe  the 
irritation  and  slight  swelling  which  remained  at  the  point  of  injury."^ 

Eust,^  Wood,  of  New  York,"*  and  others,  have  seen  and  reported 
similar  examples  attended  with  like  success. 

So  far  the  cases  of  successful  reduction  which  we  have  described 
are  examples  of  dislocation  of  only  one  of  the  articulating  apophyses, 
and  they  are  sufficiently  numerous  to  establish  the  value  of  the  prac- 
tice. We  have  now  to  relate  a  case  in  itself  unique,  namely,  a 
successful  reduction  of  a  dislocation  of  the  fifth  cervical  vertebra,  in 
which  both  apophyses  appear  to  have  been  thrown  forwards.  It 
occurred  in  the  practice  of  Dr.  Daniel  Ayres,  of  Brooklyn,  N.  Y.,  and 

'  Schrantli,  Amer.  Joum.  Med.  Sci.,  May,  1848. 
^  Maxson,  I5uffalo  Med.  Journ.,  Jan.  1857,  p.  479. 
^  Rust,  Chelius,  note  by  South, 
*  Wood,  New  York  Joum.  Med.,  Jan,  1857,  p.  13. 


512  DISLOCATIONS    OF    THE    SPINE. 

will  be  best  understood  by  a  reproduction  of  his  own  published 
account  of  the  case. 

"E.  K.,  the  subject  of  this  accident,  was  a  laboring  man,  thirty  years 
of  age,  tall  and  muscular,  but  not  fat,  with  a  neck  longer  than  the 
average  among  men  of  equal  height.  On  the  evening  of  the  2d  of 
October  he  became  intoxicated,  was  brought  home  insensible,  and  did 
not  recover  from  the  combined  effects  of  the  shock  and  his  libations 
until  the  following  morning,  when  he  was  supposed  by  his  wife  to  be 
laboring  under  cold  and  a  stiff  neck.  She  made  some  domestic  applica- 
tions to  the  affected  part,  and  administered  a  dose  of  cathartic  medicine. 
When  it  was  thought  sufficient  time  had  elapsed  without  obtaining 
relief,  he  was  seen  by  Dr.  Potter,  of  this  city,  and  afterwards  by  Dr. 
Cullen,  both  of  whom  recognized  a  condition  which  was  not  only  very 
unusual,  but  one  which  they  had  never  before  observed.  I  was  then 
requested  to  examine  the  case,  which  I  did  on  the  ninth  day  after  the 
accident.  With  some  assistance  and  great  personal  effort,  he  was 
able  to  get  out  of  bed,  moving  very  slowly  and  cautiously.  Desiring 
to  expectorate,  he  was  obliged  to  get  down  on  his  hands  and  knees, 
which  he  accomplished  with  the  same  deliberation.  When  seated  in 
a  chair,  the  head  was  thrown  back  and  permanently  fixed ;  the  face 
turned  upwards  with  an  anxious  expression.  The  anterior  portion  of 
the  neck,  bulging  forwards,  was  strongly  convex,  rendering  the  larynx 
very  prominent.  The  integuments  of  this  region  were  exceedingly 
tense  and  intolerant  of  pressure.  The  posterior  portion  of  the  neck 
exhibited  a  sharp,  sadden  angle  at  the  junction  of  the  fifth  and  sixth 
cervical  vertebras,  around  which  the  integuments  lay  in  folds.  It 
was  difficult  to  reach  the  bottom  of  this  angle  even  with  strong  pres- 
sure of  the  fingers,  and  of  course  the  regular  line  formed  by  the  pro- 
jecting spinous  processes  was  abruptly  lost.  He  complained  of  intense 
and  constant  pain  at  this  point,  which  was  neither  relieved  nor  aggra- 
vated by  pressure.  With  difficulty  he  swallowed  small  quantities  of 
liquid,  pausing  after  each  effort,  and  could  not  be  induced  to  take  solid 
food,  since  the  first  attempt  to  do  so  after  the  accident  was  followed 
by  violent  paroxysms  of  coughing  and  choking.  His  breathing 
was  obstructed  and  somewhat  labored,  being  unable  fully  to  clear 
the  bronchia  of  their  secretion.  This,  however,  seemed  rather  an  effect 
of  the  tense  condition  of  the  soft  parts  of  the  neck,  than  the  result  of 
pressure  upon  the  spinal  cord,  since  he  presented  no  evidence  of  par- 
alysis, either  of  motion  or  sensation,  in  parts  below  the  neck.  The 
sterno-cleido-mastoid  muscles  of  both  sides  were  felt  quite  soft  and 
relaxed. 

"But  one  conclusion  could  be  formed  upon  this  state  of  facts,  to 
wit :  that  the  oblique  processes  of  both  sides  were  completely  dislo- 
cated. The  marked  rigidity  of  the  head  seemed  to  preclude  the  pro- 
bability of  fracture  through  the  vertebral  bodies,  and  although  the 
cartilage  might  be  separated  anteriorly,  yet,  the  body  not  pressing 
backwards  sufficiently  to  produce  paralysis  of  the  cord,  it  was  hoped 
that  the  posterior  vertebral  ligament  remained  uninjured ;  it  was, 
therefore,  determined  to  make  an  effort  at  reduction  on  the  following 
day.     In  addition  to  those  originally  connected  with  the  case,  I  am 


DISLOCATIONS    OF    SIX    LOTVER    CERVICAL    VERTEBRA,      513 


under  obligations  to  Drs.  Ingrabam,  Turner,  Palmedo,  G.  D.  Ayres, 
and  a  number  of  other  medical  gentlemen  who  were  present  by  invita- 
tion, all  of  whom  confirmed  the  diagnosis,  and  rendered  efficient  ser- 
vices. 

"The  patient  was  placed  upon  a  strong  table  in  a  recumbent  posi- 
tion, with  a  pillow  resting  under  the  shoulders,  the  head  being  sup- 
ported by  the  hand   during  the 

administration  of  chloroform,  of  Fig-  215. 

w^hich  an  ounce  was  given  before 
anaesthesia  ensued.  Counter-ex- 
tension being  made  by  two  folded 
sheets  placed  obliquely  across  the 
shoulders  and  properly  held,  the 
head  was  grasped  by  one  hand 
placed  under  the  chin,  the  other 
over  the  occiput,  and  by  steadily 
and  firmly  drawing  the  head 
directly  backw^ards,  and  then  up- 
wards, an  attempt  was  made  at 
reduction,  but  failed  for  want  of 
sufficient  power.  Dr.  Ingraham 
was  then  requested  to  place  his 
hands  immediately  over  my  own 
in  the  same  position  as  before, 
and  steady  traction  was  again 
made  in  the  same  direction.  Our 
united  strength  was  required  in 
drawing  the  head  backwards  and 
upwards,  to  dislodge  the  superior 
oblique  processes  from  their  ab- 
normal position.  When  this  was 
felt  to  be  yielding  by  Dr.  Cullen 
(who  kept  one  hand  constantly  at  the  seat  of  dislocation).  Dr.  Potter 
was  directed  to  place  his  hands  under  our  own,  still  in  position,  and 
assist  in  bringing  the  head  forwards;  at  the  same  time  the  chest  was 
depressed  toward  the  table.  The  bones  were  distinctly  felt  to  slip 
into  their  places;  the  line  of  the  spine  was  instantly  restored,  the  head 
and  neck  assuming  their  natural  position  and  aspect.  As  soon  as  the 
patient  became  conscious,  he  expressed  himself  ignorant  of  what  had 
taken  place,  but  free  from  pain,  and,  in  his  own  language,  'all  right.' 
A  bandage  was  arranged  to  support  the  head  and  keep  it  bent  forwards. 
He  had  an  anodyne  for  two  nights  following,  after  which  no  farther 
treatment  was  necessary,  and  at  the  end  of  one  week  he  had  complete 
control  over  the  movements  of  the  head  and  neck.  Beyond  the  de- 
bility and  emaciation  immediately  dependent  upon  protracted  fasting 
and  loss  of  rest,  he  has  experienced  no  uneasiness  since  the  operation. 
His  appetite  is  now  good,  and  all  the  functions  perform  their  duty 
normally.  In  a  subsequent  inquiry,  to  determine  if  possible  the  cause 
of  the  accident,  he  states  that  he  distinctly  recollects  going  into  a  store 
in  Atlantic  Street,  near  the  ferry,  and  there  having  angry  words  with 
33 


Ayres'  case  of  bilateral  dislocation  of  the  fifth,  cer- 
vical vertebra. 


514  DISLOCATIONS    OF    THE    SPINE. 

an  acquaintance;  that  he  left  the  store  and  was  proceeding  up  the 
street  (which  is  here  a  rather  steep  ascent),  when  he  was  violently 
struck  from  behind,  over  the  lower  portion  of  the  neck.  He  likewise 
remembers  falling  forwards  and  striking  against  some  object,  but  does 
not  know  what  it  was,  nor  what  took  place  until  the  followinsr 
morning.  ' 

§  4.  Dislocations  op  the  Atlas. 

Surgeons  have  met  with  several  forms  of  displacement  between  the 
atlas  and  axis.  First,  a  forced  inclination  forwards  of  the  atlas  upon 
the  axis;  in  consequence  of  which  the  body  or  anterior  arch  of  the 
atlas  is  made  to  recede  from  the  odontoid  process,  and  the  transverse 
ligament  glides  upwards  without  breaking,  so  that  the  extremity  of 
the  odontoid  process  comes  to  occupy  a  position  underneath  or  behind 
the  ligament,  and  thus  presses  upon  the  cord.  It  is  apparent  also  that 
this  form  of  displacement  cannot  occur  without  a  rapture  of  the  verti- 
cal ligament  which  binds  the  transverse  ligament  to  the  axis,  nor 
without  a  separation  of  the  atlas  from  the  axis  posteriorly  and  a  rup- 
ture of  the  posterior  atlo-axoidean  ligament.  Second,  a  similar  incli- 
nation of  the  atlas,  accompanied  with  a  rupture  of  the  transverse 
and  superior  vertical  ligaments,  in  consequence  of  which  also  the 
odontoid  process  is  allowed  to  fall  upon  the  cord.  Third,  the  atlas 
in  the  same  position,  with  the  odontoid  process  broken  at  its  base. 
Fourth,  the  atlas  displaced  directly  forwards  or  backwards;  and 
fifth,  a  displacement  of  only  one  articular  process  in  a  direction  for- 
wards. 

"We  have  already,  when  speaking  of  fractures  of  the  atlas,  or  of  the 
atlas  and  axis  together,  called  attention  to  several  examples  of  that 
form  of  the  dislocation  which  is  accompanied  with  a  fracture  of  the 
odontoid  process.  The  other  forms  of  dislocation  are  characterized 
by  so  few  symptoms  peculiar  to  themselves,  or  which  can  be  regarded 
as  diagnostic  and  not  already  sufficiently  studied  in  connection  with 
other  dislocations  of  the  neck,  that  we  shall  not  deem  it  necessary  to 
do  more  than  remind  our  readers  that  if  permitted  to  remain  unreduced 
a  speedy  and  fatal  issue  is  inevitable,  and  to  point  them  to  a  couple  of 
examples  of  recovery  after  reduction  has  been  fortunately  accomplished, 
for  both  of  which  I  am  indebted  to  Malgaigne.  These  may  alone 
suffice  to  show  that  Dupuytren  was  in  error  when  he  declared  that 
such  accidents  were  wholly  beyond  the  resources  of  our  art. 

An  old  man  received  upon  his  head  a  bundle  of  hay  cast  from  the 
top  of  a  wagon.  He  fell  with  his  head  bent  forwards  so  that  his  chin 
touched  the  top  of  the  sternum,  and  in  this  position  it  remained  im- 
movably fixed ;  all  the  other  portions  of  his  body  preserved  their 
natural  functions.  A  surgeon,  who  was  indeed  the  father  of  Mal- 
gaigne, being  called,  assured  the  patient  that  unless  he  could  give  him 
relief  he  would  certainly  die;  but  that  inasmuch  as  the  attempt  might 
itself  prove  fatal,  he  ought  at  once  to  put  in  order  his  affairs.     Accord- 

'  Ayres,  New  York  Journ.  Med.,  Jan.  1S57,  p.  9. 


DISLOCATIOlSrS    OF    THE    HEAD    UPON    THE    ATLAS.         515 

inglj  the  man  partook  of  the  sacrament;  then  the  surgeon  seated  him 
upon  the  ground,  and  placing  himself  at  his  back  with  his  knees 
resting  upon  his  shoulders  for  the  purpose  of  making  counter-extension, 
and  with  a  towel  brought  over  his  own  shoulders  and  under  the  chin 
of  the  patient  for  extension,  he  proceeded  to  act  upon  the  neck  in  the 
direction  of  the  axis  of  the  spine.  The  efforts  were  long  and  painful, 
but  at  last,  while  the  head  was  lifted  as  far  as  possible,  it  was  suddenl}'- 
drawn  backwards,  and  immediately  it  resumed  its  natural  direction. 
Absolute  quietude  was  enjoined,  and  the  patient  recovered  in  a  short 
time  and  without  any  accident. 

This  patient  was  seen  two  years  after  by  the  younger  Malgaigne,  at 
which  time  no  trace  of  the  accident  remained  except  an  impossibility 
of  turning  the  head  to  the  right  or  to  the  left. 

The  other  example  is  related  by  Ehrlich,  but  in  this  case  the  dislo- 
cation was  backwards.  A  young  man,  ast.  16,  while  carrying  a  sack 
of  flour  up  a  ladder,  fell  backwards,  and  the  sack  falling  over  upon  his 
face  and  head  came  to  the  ground  before  him.  He  was  found  lying 
with  his  head  thrown  back  and  to  the  right,  the  head  resting  upon  the 
scapula  of  this  side,  but  having  so  completely  lost  its  "solidity"  that 
by  its  own  weight  it  would  fall  from  one  side  to  the  other.  On  the 
front  and  left  side  of  the  neck  there  existed  a  prominence  supposed 
to  be  formed  by  the  atlas ;  the  patient  was  unconscious ;  the  pulse  was 
scarcely  perceptible,  and  the  whole  body  was  suftering  under  paralysis. 
Ehrlich  directed  the  shoulders  to  be  held  by  one  assistant,  and  the 
head  to  be  drawn  upon  by  another,  while  he  pressed  with  his  own 
hands  forcibly  upon  the  displaced  atlas  from  behind.  After  several 
fruitless  attempts  the  reduction  took  place,  accompanied  with  a  sound 
distinctly  audible  to  all  of  the  assistants;  the  head  resumed  its  posi- 
tion firmly,  and  the  arms  began  to  move.  The  head  was  afterwards 
maintained  in  place  by  a  bandage.  The  cure  proceeded  rapidly,  and 
after  a  time  no  trace  of  the  injury  remained  bat  a  disagreeable  tension 
in  the  nape  of  the  neck  whenever  he  moved  his  head  briskly  to  the 
Dne  side  or  the  other.^ 


§  5.  Dislocations  of  the  Head  upon  the  Atlas,  or  OcciPiTO-ATLorDEAN 

Dislocations. 

Lassus,  Palletta  and  Bouisson^  have  each  reported  one  example  of 
this  dislocation.  In  neither  case  was  the  dislocation  complete,  but 
ieath  occurred  speedily  in  every  instance.  Dariste  exhibited  to  the 
A.natomical  Society  of  Paris,  in  1838,  a  specimen  of  incomplete  luxa- 
:ion  of  theoccipito-atloid-articulation,  with  stretching  of  the  transverse 
igament.  The  patient  from  whom  the  specimen  was  taken  having 
ived  more  than  a  year  after  the  accident,  when  he  died  from  a  tubercle 
n  the  brain.^ 

'  Malgaigne,  Ehrlich,  Malgaigne,  op.  cit.,  torn.  ii.  p.  334. 

^  Lassus,  Palletta,  Bouisson,  Malgaigne,  op.  cit.,  p.  320. 

^  Dariste,  Aaier.  Jouru.  Med.  Sci.,  ISov.  1838,  p.  237,  from  Archives  Gen.,  May, 

.638. 


516  DISLOCATIONS    OF    THE    KIBS. 


CHAPTER    IV. 

DISLOCATIONS    OF   THE   RIBS. 

The  ribs  may  be  dislocated  from  the  sternum,  from  the  vertebrae, 
and  from  each  other.  Surgeons  have  also  spoken  of  dislocations  of 
the  ribs  from  their  cartilages,  but  these  cases  ought  to  be  regarded  as 
fractures  of  the  cartilages,  since  there  is  no  proper  articulation  at 
this  point. 


§  1.  Dislocations  of  the  Ribs  from  the  Yertebr^. 

Examples  of  this  dislocation  have  been  mentioned  by  Ambrose 
Pare,  Bransby  Cooper,  Alcock,  Donne,  Henkel,  Kennedy,  Buttet,  and 
some  others ;  but  most  of  these  reputed  cases  have  not  borne  the  test 
of  a  critical  analysis,  and  while  Vidal  (de  Cassis)  is  in  doubt  whether 
the  claims  of  even  one  have  been  fully  established,  Boyer  denies  abso- 
lutely its  possibility.  We  see  no  reason,  however,  to  question  the 
authenticity  of  several  of  these  examples. 

The  case  mentioned  by  Bransby  Cooper,  although  very  briefly 
narrated,  leaves  no  room  for  doubt  as  to  its  real  character.  "  Mr. 
Webster,  surgeon  at  St.  Albans,  when  examining  the  body  of  a 
patient  who  had  died  of  fever,  found  the  head  of  the  seventh  rib 
thrown  upon  the  front  of  the  corresponding  vertebra,  and  there 
anchylosed.  Upon  inquiry,  Mr.  Webster  learned  that  this  gentle- 
man, several  years  before,  had  been  thrown  from  his  horse  across  a 
gate,  for  which  accident  he  had  been  subjected  to  the  treatment  usually 
followed  in  fractures  of  the  ribs,  and  there  is  every  reason  to  believe 
that  it  was  at  this  time  that  the  dislocation  occurred."^ 

These  accidents  seem  to  have  been  generally  occasioned  by  a  fall 
or  a  blow  upon  the  back,  and  the  dislocation  has  been  accompanied 
usually  with  a  fracture  of  some  other  rib,  or  of  the  transverse  or 
spinous  processes  of  the  corresponding  vertebrae.  The  head  of  the 
rib  has  always  been  found  to  be  displaced  inwards.  The  lower  ribs, 
including  the  false  and  floating,  are  those  which  have  been  most 
frequently  displaced. 

It  would  be  difficult,  if  not  impossible,  during  the  life  of  the  patient, 
to  make  a  positive  diagnosis,  since  the  symptoms  resemble  so  closely 
those  which  accompany  a  fracture  of  the  rib  near  its  posterior  ex- 
tremity. The  nature  of  the  accident  producing  the  dislocation,  the 
depression,  mobility,  and  pain,  are  equally  indicative  of  a  fracture ; 
while  the  failure  to  detect  crepitus  might  easily  be  explained  by  the 

'  Webster,  B.  Cooper's  ed.  of  Sir  Astley  Cooper,  Amer.  ed.,  p.  450. 


DISLOCATIONS    OF    THE    RIBS    FROM    THE    STERNUM.       617 

thickness  of  the  muscular  walls  at  this  point,  or  by  the  riding,  or  by 
other  displacements  of  the  broken  fragments. 

Chelius  speaks  of  a  peculiar  "  rustling,"  perceived  when  the  body 
and  ribs  are  moved  by  the  surgeon  or  by  the  patient  himself,  and 
which  is  different  from  the  sensation  produced  by  emphysema  or  frac- 
ture. 

The  treatment  ought  to  be  the  same  which  would  be  adopted  in 
case  the  rib  was  broken.  Replacement  of  the  dislocated  bone  must  be 
regarded  as  impossible ;  and  it  only  remains  that  we  insure  quiet  as 
far  as  possible  in  this  portion  of  the  chest,  and  combat  the  pain  and 
inflammation  by  suitable  remedies.  The  circular  bandage,  however, 
recommended  in  these  cases  by  Sir  Astley  Cooper,  could  only  be 
serviceable  in  dislocations  of  those  ribs  which  have  an  attachment  to 
the  sternum  ;  the  floating  ribs,  which  have  been  found  dislocated  quite 
as  often  as  either  of  the  others,  could  derive  no  support  from  circular 
pressure,  or  from  any  other  mechanical  contrivance. 


§  2.  Dislocations  of  the  Ribs  feom  the  Sternum. 

Charles  Bell  observes:  "A  young  man  playing  the  dumb  bells  and 
throwing  his  arms  behind  him,  feels  something  give  way  on  the  chest; 
and  one  of  the  cartilages  of  the  ribs  has  started  and  stands  prominent. 
To  reduce  it,  we  make  the  patient  draw  a  full  inspiration,  and  with 
the  fingers  knead  the  projecting  cartilage  into  its  place.  We  apply  a 
compress  and  bandage,  but  the  luxation  is  with  difficulty  retained." 

Eavaton,  Manzotti,  and  Monteggia,  have  each,  according  to  Mal- 
gaigne,  reported  one  example  of  traumatic  dislocation  ;  in  all  of  which 
the  cartilages  were  thrown  forwards  in  advance  of  the  sternum. 

By  pressure  alone  they  have  generally  been  replaced,  the  cartilage 
resuming  its  position  suddenly  and  with  a  sound.  The  reduction 
may,  nevertheless,  be  facilitated  by  bending  the  trunk  backwards  or 
by  directing  the  patient  to  make  a  full  inspiration. 

To  maintain  the  reduction  has  been  found  more  difficult,  and  Sir 
lAstley  directs  that  "a  long  piece  of  wetted  pasteboard  should  be 
placed  in  the  course  of  three  of  the  ribs  and  their  cartilages,  the 
injured  rib  being  in  the  centre;  this  dries  upon  the  chest,  takes  the 
exact  form  of  the  parts,  prevents  motion,  and  affords  the  same  support 
as  a  splint  upon  a  fractured  limb.  A  flannel  roller  is  to  be  applied 
over  this  splint,  and  a  system  of  depletion  pursued,  to  prevent  inflam- 
mation of  the  thoracic  viscera."  Instead  of  the  pasteboard,  we  might 
use  either  felt  or  gutta  percha. 

The  patients  spoken  of  by  Eavaton  and  Manzotti  were  both  cured 
in  about  one  month. 

Mr.  Bransby  Cooper  says  that  a  baker's  boy  applied  for  relief  at 
Guy's  Hospital,  who  was  the  subject  of  displacement  of  the  cartilages 
of  the  fifth  and  sixth  ribs  from  their  junction  with  the  sternum,  pro- 
duced partly  by  the  constant  action  of  the  pectoral  muscles  in  kneading 
bread,  but  principally  by  his  defective  constitution.  Mr.  Cooper  stated 
to  the  boy  the  necessity  of  changing  his  occupation,  and  advised  him 


518  DISLOCATIONS    OF    THE    CLAVICLE. 

to  go  into  the  country,  but  as  lie  was  unable  to  do  so  little  hope  was 
entertained  of  his  recovery.' 


§  3.  Dislocation  of  one  Cartilage  upon  Another. 

The  cartilages  of  the  sixth,  seventh,  and  eighth  ribs,  at  those  points 
of  their  upper  and  lower  margins  which  come  in  contact  with  each 
other,  possess  a  true  arthrodial  articulation,  being  furnished  with  both 
ligaments  and  a  synovial  membrane.  Sometimes,  also,  the  same 
anatomical  structure  extends  to  the  adjoining  surfaces  of  the  fifth  and 
sixth  ribs,  as  well  as  to  the  eighth  and  ninth. 

This  displacement,  of  which  Boyer,  Martin,  and  Malgaigne,  have 
each  reported  one  example,  may  take  place  when  one  falls  upon  his 
back,  striking  upon  some  projecting  body,  so  that  the  chest  is  suddenly 
thrown  forwards;  in  consequence  of  which  the  upper  margin  of  the 
lower  cartilage  is  depressed  and  entangled  behind  the  lower  margin 
of  the  upper.  The  inferior  cartilage  is,  therefore,  the  one  which  is 
displaced  rather  than  the  superior,  although  this  latter  being  made 
prominent  by  the  pressure  of  the  other  from  behind,  seems  alone  to 
be  displaced. 

It  is  probable  that  the  contraction  of  the  pectoral  and  abdominal 
muscles  has  a  chief  agency  in  the  production  of  these  dislocations, 
and, that  they  are  not  solely  or  directly  due  to  the  shock  of  the  acci- 
dent. 

The  treatment  consists  in  pressing  firmly  upwards  and  backwards 
against  the  inferior  margin  of  the  upper,  or  overlapping  rib,  so  as 
to  disengage  it  from  the  lower,  when  by  its  own  elasticity  it  will 
resume  its  natural  position.  The  reduction  might  also  be  aided  by  a 
full  inspiration. 


CHAPTER    V. 

DISLOCATIONS    OF    THE    CLAYIOLE. 

Of  23  dislocations  of  the  clavicle  observed  by  me,  5  belonged  to 
the  sternal  end  and  18  to  the  acromial.  Of  those  belonging  to  the 
sternal  end,  4  were  dislocations  forwards,  and  one  was  a  dislocation 
upwards.  I  have  never  met  with  a  dislocation  backwards.  Of  the 
acromial  dislocations,  the  whole  number  were  dislocations  upwards, 
or  upwards  and  outwards. 

1  B.  Cooper,  ed.  of  Sir  Astley  Cooper,  &c.,  op.  cit.,  p.  447. 


DESLOCATION"    FOEWAEDS    AT    THE    STEENAL    END. 


519 


§  1.  Dislocation  Forwards  at  the  Sternal  End. 

Causes. — This  accident  is  generally  caused  by  a  fall  upon  the  point 
of  the  shoulder,  in  consequence  of  which  the  sternal  end  of  the  cla- 
vicle is  driven  forcibly  inwards  and  forwards.  It  is  probable,  also, 
that  the  blow  which  produces  the  dislocation  is  received  rather  upon 
the  anterior  and  outer  face  than  exactly  upon  the  extremity  of  the 
shoulder.  A  sudden  effort  of  the  muscles,  as  in  the  attempt  to 
balance  a  weight  upon  the  head,  or  to  throw  the  shoulders  backwards 
when  under  drill,  has  been  known  also  to  produce  this  dislocation, 
Tn  one  example  it  was  occasioned  by  placing  the  knee  against  the 
spine  and  drawing  the  shoulders  forcibly  back.  Various  other  acci- 
dents, the  philosophy  of  whose  agency  is  not  so  easily  explained,  are 
said  to  have  produced  the  same  result;  but  it  is  not  improbable  that 
in  many  of  these  cases,  the  precise  manner  in  which  the  injury  was 
received  has  not  been  correctly  understood  or  reported. 

Mr.  Fergusson  has  once  seen  this  displacement  in  a  newly-born 
infant,  which  had  happened  daring  birth.  It  could  be  replaced  with 
ease,  but  immediately  slipped  out  again  when  left  to  itself.  "  Nothing 
was  done;  a  new  joint  formed,  and  the  child  afterwards  possessed  as 
much  power  in  the  one  arm  as  in  the  other."^ 

Si/mpioms. — The  head  of  the  bone,  unless  the  person  is  exceedingly 
fat,  or  great  swelling  has  supervened,  can  be  distinctly  felt  and  seen 
in  front  of  the  sternum ;  the  corresponding  shoulder  falls  a  little  back ; 
the  head  inclining;  also  sometimes  to  the  same  side;  the  movements  of 
the  arm  are  embarrassed,  and  accompanied  almost  always  with  an  acute 
pain  at  the  point  of  dislocation.  The  clavicular  portion  of  the  sterno- 
cleido-mastoid  muscle  presents  an  unusually  sharp  and  projecting  outline 
and  a  careful  measurement  indicates, 
if  the  dislocation  is  complete,  a  sensi- 
ble approach  of  the  acromion  process 
toward  the  centre  of  the  sternum.  If 
now  the  surgeon  places  his  knee  against 
the  spine,  and  draws  the  shoulders 
back,  the  projection  of  the  clavicle  in 
Ifront  diminishes  or  disappears;  if  he 
carries  the  shoulder  up  it  descends ; 
and  if  he  depresses  the  shoulder,  it 
ascends. 

The  simplicity  and  uniformity  of 
the  symptoms  which  usually  charac- 
terize this  accident  will  generally  pre- 
vent the  possibility  of  a  mistake;  but 
Pinel  mentions  the  case  of  a  man  who 
having  presented  himself  at  one  of  the 

hospitals  of  Paris,  suffering  under  this  dislocation,  the  surgeon  in  chief 
thought  it  a  tumor  of  the  bone,  and  advised  the  application  of  a 


Fig.  216. 


Dislocation  of  the  sternal  end  forwards. 


•  Fergnsson,  System  of  Practical  Surgery.,  Amer.  ed.,  1853,  p.  203. 


520  DISLOCATIONS    OF    THE    CLAVICLE. 

plaster;  and,  on  the  other  hand,  a  patient  presented  himself  to  Yelpeau, 
who  had  been  treated  for  a  dislocation,  when  the  bone  was  only  ex- 
panded by  disease. 

I  have  myself  also  seen  a  fracture  so  near  the  sternal  end  of  the  bone 
as  not  to  be  easily  distinguished  from  a  dislocation. 

Pathology. — In  complete  anterior  luxation  of  the  clavicle  the  cap- 
sular ligament  suffers  a  complete  disruption,  and  also  the  anterior  with 
the  posterior  sterno-clavicular  ligaments.  The  rhomboid  and  inter- 
clavicular ligaments  suffer  more  or  less  according  to  the  extent  of  the 
displacement.  The  interclavicular  cartilage  may  retain  its  attachment 
to  the  sternum,  or  it  may  be  carried  forwards  with  the  clavicle. 

The  head  of  the  bone  lies  immediately  underneath  the  skin  and  in 
front  of  the  sternum;  and  generally  it  is  found  to  have  descended  a  little 
upon  its  anterior  surface.  Eicherand  saw  a  case  in  which  the  sternal 
extremity  of  the  bone  was  placed  three  inches  below  the  top  of  the 
sternum. 

Wherever  the  bone  lies  it  carries  with  it  the  clavicular  fasciculus 
of  the  sterno-cleido-mastoid. 

Treatment, — Not  one  of  the  four  forward  dislocations  of  the  clavicle 
seen  by  me  has  been  completely  reduced,  or  if  reduced  they  have 
not  been  retained  in  place.  In  the  following  example  the  reduction, 
although  faithfully  attempted,  was  never  accomplished. 

Mr.  H.,  of  Buffalo,  get.  45,  was  thrown  by  a  horse,  suffering  at  the 
same  moment  a  fracture  of  the  leg  and  a  forward  dislocation  of  the  left 
clavicle  at  its  sternal  end. 

Prof.  James  P.  White,  of  this  city,  with  whom  I  was  in  consultation, 
made  several  attempts  to  reduce  the  dislocation  by  placing  the  knee 
against  the  spine  and  pulling  the  shoulders  forcibly  back,  and  the 
same  efforts  were  repeated  by  myself,  but  without  accomplishing  the 
reduction.  We  also  endeavored  to  reduce  it  by  pressing  directly  upon 
the  projecting  bone,  and  by  placing  a  pad  in  the  axilla,  using  the  arm 
as  a  lever  as  recommended  by  Desault,  but  with  no  better  result. 

This  patient  was  tolerably  muscular,  but  while  we  were  manipulating 
he  was  very  much  enfeebled  by  the  shock  of  the  accident. 

Finding  that  it  was  impossible  to  reduce  the  dislocation  by  any 
moderate  amount  of  force,  and  believing  that  if  we  were  to  succeed 
we  could  not  retain  the  bone  in  place,  and  the  more  especially  because 
his  left  side  was  so  much  bruised  that  he  could  not  bear  an  axillary 
pad  or  bandages  of  any  kind,  we  desisted  from  any  further  attempts. 

Two  years  later  I  examined  the  shoulder  and  found  the  clavicle  still 
unreduced,  and  its  position  unchanged.  When  he  carries  the  shoulder 
forwards  or  backwards,  there  is  a  corresponding  motion  at  the  sternal 
end  of  the  clavicle.  The  arm  is  not  quite  as  strong  as  the  other,  and 
its  freedom  of  motion  is  slightly  impaired. 

I  have  also  in  my  museum  the  cast  of  a  case  of  complete  forward 
dislocation  at  this  point;  which  accident  occurred  in  a  lad  twelve 
years  old,  who  had  fallen  into  a  cellar  on  the  20th  of  Aug.  1856,  The 
late  Dr.  Lewis  and  Dr.  Dayton,  both  excellent  surgeons  then  residing 
in  this  city,  had  examined  the  arm,  and  dressings  had  been  applied 
with  a  view  to  maintain  the  reduction ;  but  on  the  fifth  day  after  the 


DISLOCATIOISr    FORWAEDS    AT    THE    STERNAL    END.         521 

accident  I  found  the  bone  displaced ;  nor  do  I  think  redaction,  was  ever 
afterwards  maintained. 

A  lad  was  brought  into  the  hospital,  with  a  dislocation  of  the  same 
character,  on  the  2oth  of  Sept.,  1858,  who  had  been  run  over  by  a 
wagon  on  the  same  day.  Dr.  E.  P.  Smith,  one  of  the  surgeons  of 
the  hospital,  attempted  faithfully  to  reduce  it,  but  was  unable  to  do  so. 
Five  days  after,  I  found  the  bone  out  and  quite  movable.  All  appa- 
ratus having  been  removed,  we  laid  him  upon  his  back  in  bed,  and 
kept  hira  in  this  position  three  weeks.  He  was  then  dismissed,  with 
no  change  in  the  appearance  of  the  bone,  but  he  could  move  the  arm 
as  well  as  before  the  accident. 

The  fourth  example  of  which  I  have  spoken  was  only  a  partial 
luxation,  and  some  doubts  might  be  entertained  as  to  whether  it  was 
not  a  pathologic  condition;  but  after  a  careful  examination  of  the 
patient,  I  have  concluded  that  it  was  traumatic,  or  the  result  of  some 
accident,  such  as  a  sudden  and  violent  motion  of  the  arm,  and  that  in 
this  way  it  had  taken  place  without  the  knowledge  of  the  patient.  I 
found  this  man,  John  A.  Frank,  in  my  wards  at  the  hospital.  He  was 
then  fifty-nine  years  old,  and  he  stated  that  the  displacement  occurred 
when  he  was  ten  years  old  ;  nor  did  he  remember  that  it  was  the  result 
of  any  injury ;  but  only  that  one  morning  while  tying  on  his  cravat  his 
attention  was  first  called  to  it.  The  projection  has  since  then  neither 
increased  nor  diminished,  nor  has  it  ever  been  tender.  The  opposite 
clavicle  is  perfect. 

Other  surgeons  have  not  met  with,  or  at  least  they  have  not  men- 
tioned any  cases  in  which  the  reduction  of  this  dislocation  was  attended 
with  difficulty,  nor  am  I  prepared  to  explain  the  difficulty  which  was 
experienced  in  my  own  (Mr.  H.),  and  in  Dr.  E.  P.  Smith's  case.  Pro- 
bably they  ought  to  be  regarded  as  exceptions  to  the  general  rule. 
But  most  surgeons  have  testified,  to  the  difficulty  of  retaining  it  in 
place  when  reduction  has  been  fairly  accomplished.  Chelius  says, 
"there  commonly  remains  more  or  less  deformity,"  and  Malgaigne 
says  that  "  it  is  difficult  and  rare  to  cure  it  without  deformity." 

Nevertheless  Desault  (or,  rather,  his  pupil  Bichat,  who  has  published 
his  lectures),  w^ho  always  speaks  very  confidently  of  his  ability  to  retain 
either  broken  or  dislocated  bones  in  their  places,  says  that  he  "almost 
always  obtained  complete  success"  with  his  apparatus.  It  is  remark- 
able, however,  that  of  the  three  examples  famished  by  Bichat  to  con- 
firm this  statement,  all  of  which  were  treated  by  Desault  himself,  one 
recovered  after  a  long  time  with  a  "very  perceptible  protuberance  in 
front  of  the  sternum,"  one  with  a  "very  slight  protuberance,"  and  in 
the  other  the  "swelling  was  almost  gone"  on  the  twentieth  day,  and 
we  are  left  in  doubt  as  to  whether  the  reduction  was  any  more  com- 
plete than  in  either  of  the  other  cases.'  Eicherand  and  Guersant 
succeeded  no  better  with  Desault's  dressings.^ 

Other  surgeons  have  made  similar  claims  for  their  own  forms  of 
apparatus,  but  experience  still  continues  to  show  that  a  complete  re- 
tention of  the  dislocated  bone  is  seldom  to  be  expected. 

'  Desault  on  Fractures  and  Dislocations,  by  Xav.  Bichat,  Philada.  ed.,1805,  p.  53. 
^  Malgaigne,  op.  cit.,  torn.  ii.  p.  417. 


522 


DISLOCATIONS    OF    THE    CLAVICLE. 


Sir  Astlej  Cooper  recommends  an  apparatus,  the  construction  and 

application  of  which  are  illustrat- 
ing- 217.  ed  by  the  accompanying  sketch 
(Fig.  217),  the  object  of  which  is  to 
draw  the  shoulders  back,  and  at 
the  same  time,  by  the  aid  of  two 
pads  or  cushions  in  the  axillae,  to 
carry  the  shoulders  outwards. 
The  dressing  is  then  completed 
by  placing  the  arm  in  a  sling. 
He  advises,  however,  that  in 
some  way  direct  pressure  should 
be  made  upon  the  projecting 
point  of  bone. 

Velpeau  objects  to  any  plan 
which  will  draw  the  shoulders 
back ;  but,  on  the  contrary,  he 
thinks  that  the  shoulders  should 
be  kept  slightly  forwards  so  as 
to  diminish  the  tendency  of  the 
sternal  end  of  the  clavicle  to  es- 
cape in  this  direction. 

Dr.  Folts,  of  Boston,    affirms 
that  he  has  been  able  in  one  in- 
stance to  maintain  complete  re- 
duction with  Bartlett's  apparatus  for  broken  clavicles.^ 

Until  farther  observations  have  determined  the  relative  value  of 
these  and  of  many  other  processes,  it  will  be  well  to  adopt  no  fixed  rule 
of  action;  but,  having  reduced  the  bone  by  either  placing  the  knee 
upon  the  spine  and  drawing  the  shoulders  back,  or  by  making  use  of 
the  humerus  as  a  lever,  we  recommend  that  the  surgeon  shall  seek  to 
maintain  it  in  place  by  such  means  as  the  experiment  shall  prove 
are  most  successful.  Among  these  means,  direct  pressure  upon  the 
sternal  end  of  the  clavicle,  the  sling  and  perfect  quietude  of  the  muscles 
of  the  arm  through  the  aid  of  bandages,  are  no  doubt  of  the  greatest 
importance,  and  can  seldom  be  omitted.  If  then  we  find  that  a  position 
of  the  shoulders  more  or  less  forwards  or  backwards  best  maintains 
the  apposition,  this  position,  whatever  it  is,  ought  to  be  continued. 

In  order  to  be  successful,  sufficient  time  must  elapse  for  the  torn 
ligaments  to  become  firmly  reunited,  during  which  the  reduction  must 
be  constant;  since  every  time  the  bone  escapes,  the  whole  work  of 
repair  has  to  be  recommenced  as  from  the  beginning.  To  this  end  at 
least  four  or  six  weeks  are  necessary,  and  sometimes  the  period  must 
be  lengthened  far  beyond  these  limits;  so  that  it  may  often  become  a 
grave  point  of  inquiry  whether  the  long  confinement  of  the  limb  will 
not  entail  more  serious  consequences  than  have  ever  been  known  to 
arise  from  leaving  the  bone  displaced,  which  in  no  case  yet  reported 
has  more  than  slightly  impaired  the  functions  of  the  arm. 


Sir  Astiey  Cooper's  apparatus  for  dislocated  clavicle. 


'  Folts,  Boston  Med.  and  Surg.  Journ.,  vol.  liii.  p.  260. 


DISLOCATION    OF    STERN-AL    END    OF    CLAVICLE    UPWARDS.    523 


§  2.  Dislocation  op  the  Sternal  End  of  the  Clavicle  Upwards. 

Malgaigne  has  collected  four  undoubted  examples  of  this  dislocation, 
and  I  have  been  unable  to  find  a  report  of  any  other  except  the  very 
extraordinary  case  described  by  Dr.  Eochester,  of  this  city,  at  the 
September  meeting  of  the  Buffalo  Medical  Association,  and  which 
case,  through  the  courtesy  of  Dr.  Rochester,  I  was  permitted  to  see 
several  times.' 

Jerry  McAuliffe,  tet.  44,  on  the  28th  of  August,  1858,  while  seated 
upon  a  load  of  wood,  was  caught  under  the  bar  of  a  gateway  and 
violently  crushed,  the  right  shoulder  being  forced  downwards  and  a 
little  backwards.  Dr.  Rochester  saw  him  very  soon  after  the  accident. 
On  examination  it  was  found  that  the  sternal  extremity  of  the  right 
clavicle  was  thrown  upwards  so  far  as  to  rest  upon  the  front  of  the 
thyroid  cartilage,  occasioning  considerable  pain,  difficulty  of  respira- 
tion and  loss  of  speech.  Reduction  was  easily  effected,  and  a  retentive 
apparatus  was  immediately  applied,  consisting  of  a  gutta-percha  splint, 
moulded  to  the  clavicle  and  ribs,  and  retained  in  place  with  adhesive 
plaster.  Suitable  bandages,  a  sling,  &c.,  were  also  employed  to  main- 
tain complete  rest. 

Notwithstanding  all  the  care  employed,  the  bone  again  became 
displaced,  and  when,  nearly  four  months  after  the  accident,  this  man 
came  before  the  class  of  medical  students  at  the  Hospital  of  the  Sisters 
of  Charity,  we  found  the  sternal  end  of  the  clavicle  carried  upwards 
half  an  inch,  and  across  toward  the  opposite  side  also  about  half  an 
inch,  and  projecting  somewhat  in  front.  It  was  fixed  in  this  position 
by  ligaments  which  allowed  it  to  move  much  more  freely  than  natural, 
but  which  would  not  permit  any  great  displacement.  The  correspond- 
ing shoulder  was  slightly  depressed.  McAuliffe  said  that  he  felt  no 
inconvenience  or  abatement  of  strength  in  the  arm  except  when  he 
attempted  to  lift  weights  above  his  head. 

The  accident  seems  to  have  been  produced  in  all  the  cases,  so  far 
as  can  be  ascertained,  by  a  force  operating  upon  the  end  and  top  of 
the  shoulder :  in  consequence  of  which  the  head  of  the  clavicle  is 
pushed  and  at  the  same  time  lifted,  as  it  were,  from  its  socket,  tearing 
not  only  its  capsule  with  the  ligaments  which  immediately  invest  the 
ckpsule,  but  also  in  some  instances  the  costo-clavicular  ligament  with 
some  fibres  of  the  subclavian  muscle.  The  sternal  end  of  the  clavicle 
is  found  riding  upon  the  top  of  the  sternum,  its  head  being  placed 
between  the  sternal  fasciculus  of  the  sterno-cleido-mastoideus  muscle, 
on  the  one  hand,  and  the  sterno-hyoideus  muscle  on  the  other.  In 
one  of  the  cases  seen  by  Malgaigne  the  head  had  traversed  in  this 
direction  completely  the  intra-clavicular  space,  and  lay  behind  the 
sternal  portion  of  the  opposite  sterno-cleido-mastoideus  muscle. 

The  symptoms  are  a  depression  of  the  shoulder,  with  an  elevation 
of  the  sternal  end  of  the  clavicle  so  as  to  increase  sensibly  the  space 
between  it  and  the  first  rib.     The  clavicle  also  encroaches  more  or 

'  Rochester,  Buffalo  Med.  Journ.,  vol.  xiv.  p.  262. 


524  .DISLOCATIONS    OF    THE    CLAVICLE. 

less  upon  the  supra-sternal  fossa,  occasioning  a  corresponding  dimi- 
nution of  the  space  between  the  end  of  the  shoulder  and  the  centre  of 
the  sternum.  The  sternal  portion  of  one  or  both  of  the  sterno-cleido- 
mastoidean  muscles  may  also  be  seen  raised  and  rendered  tense  by  the 
pressure  of  the  head  of  the  bone  from  behind. 

Eeduction  has  been  found  easy,  but  Malgaigne  thinks  a  perfect 
retention  impossible,  at  least  it  does  not  seem  to  have  been  accom- 
plished in  any  of  the  cases  reported,  although  in  most  or  all  of  them 
the  remaining  deformity  was  only  slight.  In  no  case  did  this  trifling 
displacement  seriously  impair  the  functions  of  the  arm. 

The  same  appareil  to  which  we  shall  give  the  preference  in  cases  of 
dislocation  upwards  of  the  acromial  end  of  the  clavicle,  at  least  with 
only  such  slight  modifications  as  the  peculiarities  of  the  case  will 
naturally  suggest,  will  be  suitable  for  this  accident.  The  shoulder 
must  be  lifted  by  a  sling,  while  the  sternal  end  of  the  clavicle  is 
pressed  downwards  by  a  pad  and  bandages;  and  all  the  muscles  of  the 
arm  and  chest,  so  far  as  is  consistent  with  respiration  and  comfort, 
must  be  maintained  in  a  state  of  perfect  rest  until  the  ligaments  have 
become  reunited. 


§  3.  Dislocation  of  the  Sternal  End  op  the  Clavicle  Backwards. 

The  first  case  upon  record  of  this  kind  of  accident,  caused  by 
violence,  was  published  by  Pellieux  in  1834,  in  the  Revue  Medicale ; 
until  which  time  its  existence  had  been  generally  denied.  In  the 
London  and  Edinburgh  Journal  of  Medical  Science  for  October,  1841, 
several  cases  are  mentioned. 

Two  forms  of  the  accident  have  been  described,  one  in  which  the 
head  of  the  clavicle  is  driven  backwards  and  a  little  downwards ;  and 
another  in  which  it  is  displaced  directly  backwards,  or  backwards  and 
a  little  upwards.  In  both  of  these  classes,  the  end  of  the  bone  falls 
inwards  toward  the  opposite  clavicle,  and  occupies  a  space  in  the 
cellular  tissue  back  of  the  sterno-hyoid  and  sterno-thyroid  muscles, 
and  in  front  of  the  oesophagus ;  the  trachea,  if  reached  at  all,  being 
probably  thrust  to  the  opposite  side. 

The  examples  in  which  it  has  been  found  below  the  top  of  the 
sternum  are  much  the  most  numerous;  indeed,  it  is  probable  that  the 
other  form  is  only  a  secondary  displacement,  occasioned  by  the  action 
of  the  fibres  of  the  sterno-cleido-mastoid  muscle. 

Causes. — Of  the  eleven  examples  mentioned  by  Malgaigne,  four 
were  occasioned  by  direct  blows,  and  most  of  the  remainder  by  crush- 
ing accidents,  as  by  powerful  lateral  compression  of  the  shoulders. 

One  of  the  cases  produced  by  a  direct  blow,  was  accompanied  with 
an  external  wound,  and  is  the  only  instance  of  a  compound  dislocation 
of  this  kind  upon  record.  The  man  was  admitted  into  St.  Thomas's 
Hospital  in  Sept.  1835,  and,  according  to  his  own  account,  the  sharp 
end  of  a  pickaxe  had  been  driven  through  the  flesh  against  the  bone. 
The  sternal  end  of  the  clavicle  was  found  to  be  displaced  backwards, 
and,  with  the  finger  thrust  into  the  wound  on  the  front  of  the  chest,  it 


DISLOCATION  OF  STEENAL  END  OF  CLAVICLE  BACKWAEDS.  525 

could  be  distinctly  felt  resting  upon  the  side  and  front  of  the  trachea, 
where  it  interfered  somewhat  with  respiration  and  deglutition.  He 
had  a  great  desire  to  cough,  with  a  sensation  of  pressure  on  his  wind- 
pipe, which  was  greatly  increased  when  his  head  was  thrown  back. 
There  was  also  a  slight  emphysema  in  the  region  below  the  collar 
bone  and  over  the  top  of  the  sternum.  The  shoulder  having  been 
brought  back  with  straps  attached  to  a  back-board  the  bone  readily 
resumed  its  place.  The  elbow  was  then  brought  forwards  and  bound 
to  the  side,  and  the  wound  being  closed  with  adhesive  plaster,  he  was 
put  to  bed  with  the  shoulders  much  raised.  No  unfavorable  symptoms 
followed,  and  in  three  weeks  he  left  his  bed.  Three  weeks  later  he 
left  the  hospital  with  the  sternal  end  of  the  bone  still  falling  a  little 
backwards,  and  rather  more  movable  than  natural.' 

The  following  example,  related  by  Morel-Lavall^e,  will  illustrate 
that  class  in  which  the  dislocation  results  from  an  indirect  blow,  or 
from  a  crushing  accident. 

Lemoine,  seventeen  years  old,  had  his  right  shoulder  violently 
pressed  against  a  wall  by  a  carriage.  He  experienced  at  the  moment 
some  pain  at  the  bottom  of  his  neck,  and  a  great  sensation  of  suffocation, 
which  lasted  for  more  than  a  quarter  of  an  hour.  The  dyspnoea  gradu- 
ally subsided,  but  the  motion  of  the  right  arm  not  returning,  he,  on 
the  eighth  day  after  the  accident,  entered  La  Charitd.  On  examination, 
the  two  shoulders  were  found  to  be  on  the  same  level,  but  the  right 
one  was  nearer  the  mesial  line.  The  internal  extremity  of  the  clavicle 
was  half  concealed  behind  the  sternum.  On  depressing  the  shoulder, 
the  inner  end  of  the  clavicle  arose  and  disengaged  itself  from  behind 
the  sternum ;  but  reduction  was  effected  by  elevating  the  shoulder, 
while  at  the  same  time  it  was  carried  outwards  and  backwards.  De- 
sault's  bandage  was  then  applied,  but  as  it  became  loosened,  Velpeau's 
was  substituted,  which  kept  the  bone  completely  in  position  until  the 
eighteenth  day,  when  the  patient  was  lost  sight  of.^ 

Symptoms. — The  most  constant  symptoms  are  the  absence  of  the 
head  of  the  bone  from  its  socket,  and  its  complete  or  partial  disappear- 
ance behind  the  sternum,  an  approach  of  the  corresponding  shoulder 
to  the  mesian  line,  an  inclination  of  the  head  to  the  opposite  side,  eleva- 
tion of  the  shoulder,  pain  at  bottom  of  the  neck,  impairment  of  the 
motions  of  the  arm,  sometimes  difficulty  in  respiration  and  in  deglu- 
tition, partial  arrest  in  the  circulation  of  the  arm  from  pressure  upon 
the  subclavian  artery,  and  a  slight  projection  of  the  acromial  end  of 
I  the  clavicle,  noticed  twice  by  Morel-Lavallee. 

It  has  not  generally  been  found  difficult  to  reduce  this  dislocation, 
nor,  when  reduced,  is  it  so  liable  to  again  become  displaced  as  are  the 
dislocations  forwards ;  yet  in  only  a  few  instances  has  the  restoration 
been  so  complete  as  not  to  leave  some  deformity. 

In  order  to  the  reduction,  the  shoulder  must  be  carried  generally 
upwards,  outwards,  and  backwards,  and  it  may  then  be  best  main- 
tained in  position  by  laying  the  patient  on  his  back  upon  an  elevated 

'  South,  note  to  Chelius's  Surgery,  Araer.  ed.,  voL  ii.  p.  218. 

2  Morel-Lavallee,  Amer.  Journ.  Med.  Sci.,  vol.  xxix.  p.  229,  1842 ;  from  Gaz.  Med. 


626  DisLocATioisrs  of  the  clavicle. 

cnshioD,  as  practised  by  Tyrrell  in  the  ease  related  by  Soutli.  To  this 
may  be  added  such  other  measures,  differing  but  little  from  those  em- 
ployed in  other  dislocations  of  the  clavicle,  as  are  necessary  to  insure 
complete  rest  to  the  muscles.  Of  course,  no  pads  or  bands  across  the 
clavicle  can  be  of  any  service  in  this  case. 

As  in  the  other  cases  of  dislocation  at  this  point,  the  patients  have 
generally  recovered  nearly  the  full  use  of  their  arms,  even  in  one  or 
two  instances  in  which  the  reduction  has  never  been  accomplished. 


§  4.  Dislocation  of  the  Acromial  End  or  the  Clavicle  Upwards. 

Of  all  the  dislocations  of  the  clavicle,  this  form  is  most  frequent. 
I  have  met  with  it  either  as  a  partial  or  complete  luxation  eighteen 
times.  The  youngest  subject  was  seven  years  of  age,  and  the  oldest 
sixty-three.     All  but  one  were  males. 

Causes. — It  is  produced  generally  by  a  fall  upon  the  extremity  of  the 
shoulder.  Twice  the  blow  has  been  received  rather  upon  the  back 
than  upon  the  extremity,  and  once  it  was  occasioned  by  the  fall  of  a 
board  directly  upon  the  top  of  the  shoulder. 

SymjMms. — When  the  dislocation  is  complete,  the  clavicle  not  only 
is  lifted  from  its  articular  facet  to  the  extent  of  the  breadth  of  the  booe, 
but  it  is  pushed  more  or  less  outwards  over  the  top  of  the  acromion 
process;  generally  less  than  half  an  inch,  but  I  have  once  seen  it 
riding  the  process  to  the  extent  of  three-quarters  of  an  inch.  In  this 
last  example,  the  case  of  James  Moran,  a  strong,  healthy  laboring  man, 
the  clavicle  was  easily  reduced,  and  it  always  went  into  place  with  a 
sensible  click ;  but  although  every  possible  care  was  taken  to  retain  it 
in  place  by  bandages,  compresses,  an  axillary  pad  and  a  sling,  yet  it 
was  not  accomplished,  and  on  the  third  day  he  removed  all  the  dress- 
ings, and  refused  to  have  them  reapplied. 

I  have  usually  found  the  shoulder  slightly  depressed,  and  in  one 
instance,  where  it  is  probable  the  deltoid  muscle  had  suffered  some  in- 
jury, the  elbow  hung  away  from  the  body,  and  any  attempts  to  lay  it 
against  the  side  produced  an  acute  pain  in  the  shoulder.^  It  has  been 
noticed  also,  in  most  cases,  that  the  clavicular  portion  of  the  trapezius 
muscle  appeared  lifted  and  tense,  especially  when  the  neck  was 
straight. 

Inability  to  raise  the  arm  to  a  right  angle  with  the  body  is  a  general 
but  not  constant  symptom.  In  two  instances  where  the  displacement 
was  only  moderate,  the  patients  were  at  first  and  for  some  time  after- 
wards unable  to  lift  the  arm  in  any  degree  from  the  side.  In  one 
example,  a  lady  sixty  years  of  age  had  fallen  upon  her  shoulder  and 
produced  a  dislocation  upwards,  but  she  had  not  consulted  a  surgeon 
until  she  called  upon  me,  five  months  after  the  accident.  The  clavicle 
was  then  raised  from  its  socket  about  half  an  inch,  but  it  could  be 
easily  pressed  back  to  its  place,  the  reduction  being  attended  with  a 

1  Report  on  Dislocations,  by  the  author.  Transac.  of  New  York  State  Med.  See,  1855, 
p.  19. 


DISLOCATION  OF  ACEOMIAL  END  OF  CLAVICLE  UPWARDS.      527 


Fiff.  218. 


Dislocation  of  the  acromial  end  of  the 
clavicle,  upwards  and  outwards. 


grating  sensation,  a  circumstance  which  I  have  not  noticed  in  any- 
other  instance.     She  was  not  even  then  able  to  raise  her  arm  to  her 
head,  nor  had  she  been  able  to  do  so  since 
the  accideni  occurred. 

In  all  the  motions  of  the  arm  and  shoul- 
der, the  clavicle  is  seen  to  move  more 
freely  than  natural  immediately  under  the 
skin,  and  these  motions  are  usually  at- 
tended with  some  pain  at  the  point  of  dis- 
location. 

This  accident  has  been  sometimes  mis- 
taken for  a  dislocation  of  the  humerus, 
but  unless  the  shoulder  is  already  greatly 
swollen,  the  error  is  not  likely  to  happen. 
If  the  point  of  the  acromion  process  can 
be  made  out,  it  will  be  easy  to  determine, 
by  sliding  the  finger  along  its  spine, 
whether  the  clavicle  is  displaced  or  not, 
and  by  these  means  to  settle  the  question 
of  its  complicity  in  the  accident.  The 
question  as  to  whether  the  shoulder  is 
dislocated  or  not  may  be  more  difficult  of 
solution,  as  we  shall  hereafter  have  occa- 
sion again  to  observe. 

Pathology. — Generally  there  exists  simply  a  rupture  of  the  capsule 
of  the  joint,  and  of  the  ligaments  immediately  investing  the  capsule,  so 
that  the  clavicle  rises  from  its  socket  only  about  half  an  inch,  more  or 
less,  according  to  its  diameter,  and  is  carried  outwards  just  sufficiently 
far  to  allow  it  to  rest  upon  the  upper  margin  of  the  acromial  articula- 
tion. In  at  least  thirteen  of  the  cases  seen  by  me,  this  has  been  the 
position  of  the  acromial  end  of  the  clavicle,  and  for  its  complete 
reduction  nothing  more  has  been  required  than  to  press  with  moderate 
Ibrce  upon  the  upper  and  outer  end  of  the  bone. 

In  three  cases  I  have  found  the  bone  not  only  thus  lifted  in  its 
socket,  but  also  driven  over  upon  the  acromion  from  half  to  three- 
quarters  of  an  inch;  and  in  one  instance,  that  of  a  gentleman,  Mr.  B., 
who  was  injured  in  a  railroad  accident,  the  acromial  end  of  the 
clavicle  was  displaced  outwards  half  an  inch  and  backwards  three- 
quarters  of  an  inch,  while  the  sternal  end  also  was  considerably  lifted 
in  its  socket  and  slightly  sent  inwards.  The  head  of  the  humerus 
fell  forwards  and  the  coracoid  process  was  one  inch  nearer  the  sternum 
than  the  same  process  upon  the  opposite  side.  In  such  cases  more  or 
less  of  the  fibres  of  the  coraco-clavicular  ligament  must  have  suffered 
a  disruption ;  indeed,  without  a  rupture  of  its  external  fasciculus,  which 
matomists  have  called  the  trapezoid  ligament,  such  a  dislocation  can- 
lot  take  place. 

Prognosis. — It  is  impossible  for  me  to  say  what  has  been  the  precise 
^esult  in  all  the  cases  which  I  have  seen,  but  my  notes  furnish  only 
pne  case  of  perfect  retention  after  a  complete  dislocation  at  this  point, 
David  Thomas,  aged  about  twenty-five  years,  fell  sideways  upon  the 


528  DISLOCATIONS    OF    THE    CLAVICLE. 

ground,  striking  upon  the  extremity,  and,  as  he  thinks,  a  little  upon 
the  top  of  the  shoulder.  I  found  the  clavicle  dislocated  upwards  and 
outwards,  so  that  it  overlapped  the  acromion  process  half  an  inch. 
It  was  easily  replaced,  and  having  applied  my  own  apparatus  for 
broken  collar  bones,  with  the  addition  of  a  band  across  the  shoulder 
and  under  the  elbow  to  keep  the  clavicle  down,  I  found  that  I  had 
succeeded  in  retaining  the  bone  in  place.  This  dressing  was  continued 
until  the  forty-second  day,  when,  on  being  removed,  the  clavicle  was 
seen  to  be  closely  confined  upon  its  articulation  ;  and  after  a  lapse  of 
two  years  it  still  retains  its  position  so  completely  that  no  difference 
can  be  detected  between  the  opposite  articulations. 

In  the  case  of  Moran,  already  mentioned,  whose  clavicle  overlapped 
the  acromion  process  three  quarters  of  an  inch,  and  who  threw  off  the 
dressings  at  the  end  of  three  days,  the  same  degree  of  displacement 
existed  at  the  end  of  two  years :  the  scapular  end  of  the  clavicle  moving 
freely  in  every  direction  under  the  skin  according  as  the  arm  was 
moved.  In  lifting,  he  says,  the  strength  of  his  arm  is  undiminished 
until  he  raises  the  weight  nearly  to  a  level  with  his  shoulders,  and 
from  this  point  upwards  he  can  lift  but  little.  For  a  laboring  man 
it  amounts  to  a  serious  maiming.  I  have  seen  the  same  loss  of 
power  in  the  arm  to  raise  bodies  above  the  head  in  at  least  two  or 
three  of  the  examples  of  less  complete  luxation,  continuing  after  the 
lapse  of  several  years ;  but  in  the  majority  of  cases,  although  the  bone 
does  not  remain  reduced,  the  patients  have  recovered  eventually  the 
complete  use  of  the  arm  in  whatever  position  it  may  be  placed. 

Treatment. — When  the  bone  simply  rises  upon  its  socket  the  re- 
duction is  always  easily  accomplished  by  pressing  firmly  upon  its 
extremity  with  the  fingers;  but  if,  at  the  same  time,  it  has  been  carried 
outwards,  or  outwards  and  backwards,  the  reduction  is  only  accom- 
plished by  pulling  the  shoulders  backwards,  or  by  placing  a  pad  in 
the  axilla,  using  the  arm  as  a  lever,  or  by  lifting  the  arm  by  the  elbow 
and  at  the  same  time  pressing  the  clavicle  down  ;  and  it  will  sometimes 
require  the  application  of  all  or  several  of  these  procedures  at  the 
same  moment.  In  some  cases  the  complete  reduction  has  only  been 
effected  when  the  patient  has  been  brought  under  the  influence  of  an 
anaesthetic. 

As  to  the  maintenance  of  the  bone  in  its  socket  for  a  length  of  time 
sufficient  to  insure  a  firm  union  of  the  broken  tissues,  this  will  be 
fiound  always  more  difficult,  and,  in  a  great  majority  of  cases,  absolutely 
impossible.  Nearly  all  surgeons  who  have  written  upon  this  subject 
have  made  the  same  observation ;  and  if  occasionally  a  new  apparatus 
in  the  hands  of  a  clever  surgeon  has  seemed  to  promise  better  results, 
the  same  apparatus  in  the  hands  of  other  equally  clever  surgeons,  and 
under  circumstances  equally  favorable,  has  been  found  almost  con- 
stantly to  fail ;  and  we  have  been  compelled  again  to  exercise  anew 
our  ingenuity,  and  to  seek  for  new  resources,  or  to  abandon  the  eftbrt 
in  despair. 

Only  very  lately  a  surgeon.  Dr.  Folts,  of  Boston,  believed  that  he 
had  found  in  Bartlett's  apparatus  for  broken  clavicles  modified  by  the 
application  of  a  shoulder-strap,  the  infallible  remedy  for  this  one  of 


OF    THE   ACROMIAL    END    OF    CLAVICLE    UPWARDS.        529 


the  many  sad  defects  ia  our  art.  The  most  important  part  of  this 
dressing,  according  to  Dr.  Folts,  is  the  compress  placed  upon  the  upper 
and  outer  end  of  the  clavicle,  and  the  bandage  or  strap  passed  over  the 
compress  and  under  the  point  of  the  elbow  to  maintain  it  in  position.^ 

Dr.  Folts  is  no  doubt  correct  in  regarding  this  strap  as  an  impor- 
tant if  not  the  essential  part  of  the  apparatus;  and  it  is  surprising 
that  by  Sir  Astley  Cooper,  as  well  as  by  many  other  experienced  sur- 
geons, its  value  should  have  been  overlooked.  The  chief  obstacle  to 
the  retention  of  the  bone  in  place  is  the  powerful  action  of  the  tra- 
pezius, which  constantly  tends  to  elevate  the  outer  end  of  the  bone. 
In  some  measure  this  may  be  resisted  by  elevating  very  forcibly 
the  shoulder,  or  by  inclining  the  head,  but  both  of  these  positions  are 
extremely  fatiguing,  and  will  not  be  long  endured.  The  bandage  or 
strap,  adjusted  in  the  manner  which  Dr.  Folts  has  recommended,  is  the 
only  means  of  counteracting  the  action  of  the  trapezius,  upon  which 
any  substantial  reliance  can  be  placed;  but  the  principle  has  long  been 
understood  and  practiced  upon.  Brasdor's  tou rniquet,  or  Petit's,  secured 
by  a  strap  brought  under  the  point  of  the  elbow,  Boyer's  double  shoul- 
der straps  and  Desault's  third  bandage,  all  aimed  at  the  accomplishment 
of  the  same  purpose ;  yet  both  Boyer  and  Desault  found  all  these  con- 
trivances fail  in  a  majority  of  cases.  Mayor  employed  a  dressing  con- 
structed with  a  strap  to  buckle  over  the  dislocated  clavicle  (Fig.  219); 
but  Nelaton  has  seen  this  appa- 
ratus fail,  also,  when  applied  in  Fig.  219. 
his  own  wards. 

The  experience  of  Dr.  Folts 
at  the  time  of  his  report  did  not 
extend  beyond  three  cases,  and 
the  apparatus  had  been  com- 
pletely successful  in  only  two  of 
the  three.  Our  own  experience 
is  sufficient  to  show  that  it  will 
be  found  occasionally,  but  by 
no  means  constantly,  successful. 
We  have  already  mentioned  one 
case  in  which  we  succeeded  per- 
fectly by  this  mode,  but  in  seve- 
ral others  which  seemed  equally 
favorable  we  have  met  with  par- 
tial or  complete  failures. 

The  practical  difficulties  are, 
the  sensibility  and  consequent 
inability  sometimes  of  the  point 
of  the  elbow  to  bear  the  requi- 
site pressure,  and  the  even  greater 
sensibility  of  the  skin  over  the 
top  of  the  clavicle;  the  tendency  of  the  bandage  to  slide  off  from  the 
shoulder  and  also  to  become  displaced  from  the  end  of  the  elbow ;  the 


Mayors  apparatus  for  dislocated  clavicle.    ("Trian- 
gle cubito-bis-scapulaire.") 


34 


1  Folts,  Bost.  Med.  and  Surg.  Journ.,  vol.  liii.  p.  259. 


530  DISLOCATIONS    OF    THE    CLAVICLE. 

gradual  relaxation  of  the  bandages,  wbich,  when  existing  even  in  the 
most  inconsiderable  degree,  is  sufficient  sometimes  to  allow  the  bone 
to  slip  out  from  its  shallow  socket;  the  impossibility  of  fixing  the 
scapula,  upon  whose  immobility  as  well  as  upon  the  immobility  of  the 
clavicle  the  retention  depends;  and,  finally,  the  great  length  of  time 
requisite  to  unite  firmly  the  ligaments  and  the  capsule,  if  indeed  they 
ever  again  become  actually  united. 

The  band  can  be  prevented  in  some  measure  from  sliding  off  from 
the  clavicle  by  a  counter-band  attached  to  a  collar  upon  the  opposite 
shoulder,  but  not  without  causing  some  pain  and  giving  rise  to  exco- 
riations generally  in  the  opposite  axilla;  and  in  a  degree  all  the  other 
difficulties  may  be  met  by  patience  and  ingenuity,  but  unfortunately 
the  smallest  failure  in  any  one  of  these  numerous  indications  insures 
a  defeat. 

The  axillary  pad  employed  as  a  fulcrum  upon  which  extension  may 
be  made  is  equally  as  dangerous  here  as  in  fractures,  and  I  do  not 
think  it  ought  ever  to  be  used  for  this  purpose,  but  only  as  a  means 
of  moderate  support  and  retention ;  indeed  it  would  be  well,  perhaps, 
if  it  were  discarded  altogether. 

The  case  of  Mr,  B.,  already  quoted,  with  a  dislocation  outwards  and 
backwards,  affords  not  only  an  illustration  of  the  inefficiency  of  either 
the  shoulder-strap  or  the  axillary  pad  in  certain  cases,  but  also,  it  seems 
to  me,  of  the  mischief  which  may  result  from  their  too  diligent  appli- 
catiqn  ;  for  I  cannot  persuade  myself  but  that  most  of  the  maiming  in 
this  case  was  due  to  the  apparatus  rather  than  to  the  original  accident. 

This  gentleman  was  injured  on  the  10th  of  November,  1855.  A  sling 
with  an  axillary  pad  and  bandages  was  immediately  applied.  I  saw 
him  on  the  seventeenth  day.  The  displacement  was  then  such  as  I 
have  described,  but  I  did  not  observe  any  paralysis  or  emaciation  of 
the  limb.  Having  noticed  that  the  clavicle  fell  into  its  socket  when 
he  lay  upon  his  back  in  bed,  at  my  suggestion  all  the  dressings  ex- 
cept the  sling  were  removed,  and  the  patient  was  laid  upon  his  back 
in  bed,  with  instructions  to  continue  in  this  position  if  possible  until 
the  cure  was  completed;  but  after  a  few  days  I  received  a  communi- 
cation from  his  physician,  stating  that,  owing  to  a  troublesome  cough, 
he  had  found  it  impossible  to  maintain  this  position.  His  residence 
was  forty  or  fifty  miles  from  town,  and  I  sent  him  one  of  my  dressings 
for  broken  collar  bones  with  instructions  as  to  its  use;  directing 
especially  that  a  shoulder-strap  should  be  used  to  keep  the  clavicle 
down. 

The  dressing  was  applied  and  continued  six  weeks,  and  on  being 
removed,  the  elbow,  wrist,  and  finger-joints  were  found  to  be  stiff. 
The  whole  arm  was  emaciated  and  almost  powerless.  One  year  later 
there  was  no  improvement  in  the  condition  of  the  arm ;  every  joint 
from  the  shoulder  down  was  almost  completely  anchylosed,  the 
muscles  were  greatly  wasted,  and  the  hand  trembled  constantly. 

These  results,  it  seems  to  me,  were  due  to  too  long  and  too  tight 
bandaging  of  the  arm,  and  especially  to  the  pressure  of  the  axillary 
pad.     I  do  not  state  this  positively,  but  this  is  my  belief. 

Is  it  worth  while,  then,  to  incur  the  dangers  of  too  long  confinement 


OF    THE    ACEOMIAL    END    OF    CLAVICLE    DOWNWAEDS.      531 

and  of  excessive  bandaging  for  the  purpose  of  attaining  the  ahvays 
uncertain  result  of  maintaining  the  bone  in  its  socket  ?  We  certainly 
may  be  permitted  to  make  the  attempt  within  certain  reasonable 
limits ;  and  especially  if  the  patient  is  a  female  and  the  avoidance  of 
deformity  is  a  point  of  serious  consideration ;  but  never  without  keep- 
ing constantly  in  mind  the  possibility  of  a  permanent  anchylosis  and 
paralysis  of  the  limb. 


§  5.  Dislocation  or  the  Acromial  End  of  the  Clavicle  Downwards. 

This  form  of  dislocation  is  exceedingly  rare,  only  three  well- 
authenticated  cases  having  been  placed  upon  record,  one  of  which 
was  seen  and  dissected  by  Melle,  in  1765,  the  second  was  met  with  by 
Fleury,  in  1816,  and  the  third  is  described  by  Tournel. 

Cause. — So  far  as  we  can  ascertain,  it  has  been  produced  only  by  a 
force  which  has  acted  directly  upon  the  top  of  the  clavicle.  In  the 
case  mentioned  by  Tournel,  a  horse  had  trod  upon  the  shoulder,  and 
in  the  example  recorded  by  Melle,  the  accident  occurred  in  a  child 
six  years  old,  from  an  attempt  to  support  a  great  weight  upon  the  top 
of  the  collar  bone.  In  this  last  example  the  shoulder  was  dislocated 
also,  and  both  dislocations  had  remained  unreduced  many  years  when 
the  patient  was  seen  by  Melle. 

This  force  acting  directly  upon  the  top  of  the  clavicle  would  fail  to 
dislocate  the  bone,  except  by  first  breaking  down  the  coracoid  process, 
if  it  did  not  happen  sometimes  that  at  the  same  moment  the  lower 
angle  of  the  scapula  was  thrown  outwards,  in  such  a  manner  as  to 
depress  slightly  the  coracoid,  and  thus  to  permit  the  outer  end  of  the 
clavicle  to  fall  below  the  level  of  the  acromion  process. 

Symptoms  and  Pathology. — This  dislocation,  whether  it  has  been  pro- 
duced artificially  upon  the  dead  subject  or  accidentally  upon  the  living, 
has  always  been  found  to  be  accompanied  with  a  complete  rupture  of 
tlie  acromio-clavicular  ligaments  not  only,  but  also  of  the  coraco- 
acromial  and  coraco-clavicular  ligaments;  the  outer  extremity  of  the 
bone  resting  between  the  acromion  process  and  the  capsule  of  the 
shoulder-joint,  and  a  little  posterior  to  the  articulating  facet  which 
originally  received  the  clavicle. 

The  superior  angle  of  the  scapula  approaches  the  body  slightly,  and 
its  inferior  angle  is  thrown  outwards.  A  marked  depression  exists  at 
the  point  of  dislocation,  accompanied  with  a  sharp  pain,  increased 
especially  when  an  attempt  is  made  to  move  the  arm.  The  patient 
is  unable  to  lift  the  arm  voluntarily,  but  it  can  be  moved  pretty  freely 
in  the  direction  forwards  and  backwards  by  the  hands  of  the  surgeon  : 
abduction  is  much  more  dif&cult. 

Treatment. — Keduction  is  easily  accomplished,  at  least  in  the  only 
two  examples  upon  the  living  subject  in  which  the  attempt  has  been 
made,  it  was  efiected  promptly  by  drawing  the  shoulders  gently  out- 
wards and  backwards ;  nor  has  it  been  found  any  more  difficult  to 
maintain  it  in  position  when  once  replaced.  When  the  scapula  is  re- 
stored to  its  natural  position  and  its  lower  angle  approaches  again  the 


532  DISLOCATIONS    OF    THE    CLAVICLE. 

side  of  the  body,  a  reluxation  becomes  impossible;  since  the  coracoid 
process  now  effectually  prevents  that  descent  of  the  clavicle  upon  which 
its  displacement  always  depends.  It  is  only  necessary,  therefore,  to 
secure  the  scapula  at  its  base  and  lower  angle  snugly  to  the  body,  by  a 
broad  band  and  compress,  and  all  the  indications  of  treatment  are 
completely  fulfilled. 


§  6.  Dislocation  op  the  Acromial  End  of  the  Clavicle  under  the 
Coracoid  Process. 

Pinjou  met  with  one  example  of  this  singular  dislocation,'  and  Gode- 
raer,  of  Mayenne,  has  recorded  five  more,^  and  these  constitute  the 
whole  number  which  are  at  this  day  known  to  science. 

Cause. — Age  and  a  consequent  relaxation  of  the  ligaments  seem  to 
constitute  a  predisposing  cause,  since  of  the  six  recorded  examples 
four  were  between  the  ages  of  sixty-seven  and  seventy-one,  and  the 
other  two  were  adults.  In  all  the  cases,  also,  the  dislocation  was  the 
result  of  a  fall  upon  the  shoulder. 

The  symptoms  which  have  been  said  to  characterize  this  accident 
are  pain  and  a  very  marked  depression  at  the  point  of  displacement, 
with  a  corresponding  projection  of  the  acromion  and  coracoid  processes; 
a  rapid  inclination  outwards  and  downwards  of  the  line  of  the  clavicle, 
its  outer  extremity  being  felt  in  the  axilla  ;  the  corresponding  shoul- 
der depressed  and  inclined  forwards  ;  freedom  of  motion  in  all  directions 
except  inwards  and  upwards;  the  lower  angle  of  the  scapula  thrown 
outwards  and  backwards ;  to  which  Morel-Lavall^  has  added  an 
actual  increase  of  space  between  the  acromion  process  and  the  sternum. 

Treatment. — Godemer  reduced  all  the  examples  which  came  under 
his  notice  easily  by  directing  an  assistant  to  pull  the  arm  backwards 
and  outwards  while  he  himself  seized  upon  the  clavicle  with  his 
fingers  and  disengaged  it  from  under  the  process;  but  Pinjou,  after 
many  efforts  by  the  same  method,  failed  completely,  and  the  patient 
having  left  him,  the  clavicle  was  reduced  the  next  day  by  an  empiric. 
Vidal  (de  Cassis)  recommends  that  instead  of  pulling  the  arm  out- 
wards, by  which  procedure  the  pectoralis  major  is  made  to  antago- 
nize the  surgeon,  the  elbow  shall  be  brought  down  to  the  side,  and 
kept  there  by  the  left  hand,  while  the  right  hand,  placed  in  the  axilla, 
shall  pull  the  upper  end  of  the  humerus  outwards,  converting  the  arm 
into  a  lever  of  the  third  kind.  This  process,  I  confess,  seems  to  be 
much  the  most  rational. 

Finally,  having  given  the  history  of  these  cases  as  they  have  been 
reported,  we  shall  scarcely  have  performed  our  duty  as  a  faithful 
writer  if  we  do  not  state  frankly  that  we  entertain  a  suspicion  that 
both  the  gentlemen  who  have  reported  these  curious  examples  have 
entertained  us  with  fabulous  or  imaginary  stories ;  and  especially  do 
these  suspicions  rest  upon  the  cases  reported  by  Godemer,  who  in  five 

1  Pinjou,  Journ.  de  Med.  de  Lyon,  Juillet,  1842,  from  Vidal  (de  Cassis). 

^  Godemer,  Recueil  des  travaux  de  la  Soc.  Med  d'Indre  et  Loire,  1843,  from  Vidal. 


DISLOCATION    OF    THE    SHOULDER    DOWNWAEDS.  533 

years  saw  five  cases,  each  presenting  throughout  the  same  class  of 
symptoms,  the  same  facility  of  reduction,  accomplished  by  the  same 
means,  and  always  with  the  same  perfect  result. 

If  to  these  singular  coincidences  we  add  the  fact  that  only  one  other 
surgeon  has  ever  claimed  to  have  met  with  the  accident,  and  if  we 
notice  the  actual  anatomical  difficulties  which  stand  in  the  way  of  its 
occurrence,  such  especially  as  the  complete  occlusion  of  the  subcora- 
coidean  space  by  the  tendons  and  muscles  which  pass  from  its 
extremity  toward  the  chest  and  arm,  we  shall  find  a  fair  apology  for 
some  degree  of  scepticism. 


CHAPTER    VI. 

DISLOCATIONS    OF     THE     SHOULDEE     (HUMEEUS    AT 
ITS    UPPEE    EXTEE^kllTY). 

Owing  to  the  great  exposure,  and  the  peculiar  anatomical  structure 
of  the  shoulder-joint,  its  structure  having  reference  mainly  to  freedom 
of  motion  rather  than  to  firmness  and  security  in  the  articulation, 
dislocations  of  the  humerus  are  very  common. 

Writers  have  not  been  agreed  as  to  the  precise  anatomical  relations 
of  these  dislocations,  nor  as  to  the  nomenclature.  Yelpeau,  Malgaigne, 
Vidal  (de  Cassis),  Skey,  and  Sir  Astley  Cooper,  have  each  adopted 
explanations  and  classifications  peculiar  to  themselves.  With  the 
arrangement  established  by  this  latter  surgeon,  English  and  American 
students  are  the  most  familiar;  and  believing  that  it  is  more  simple, 
and  quite  as  appropriate  as  either  of  the  others,  I  shall  adopt  it  as  the 
basis  of  my  own  descriptions. 

I  shall  have  occasion,  however,  to  dissent  from  the  opinions  and 
teachings  of  this  distinguished  surgeon,  as  to  the  exact  seat  and 
relations  of  the  head  of  the  humerus  in  some  of  these  dislocations. 

According  to  Sir  Astley  Cooper,  there  are  three  complete  luxations 
of  the  shoulder,  namely,  downwards,  forwards,  and  backwards. 


§  1.  Dislocation  of  the  Shoulder  Downwards.    (Subglenoid.) 

This  is  usually  called  a  dislocation  into  the  axilla;  the  head  of  the 
bone  resting  rather  upon  the  inner  side  of  the  inferior  border  of  the 
scapula,  near  the  base  of  that  triangular  surface  which  is  found  below 
the  glenoid  fossa. 

Since  in  both  the  other  complete  dislocations  of  the  shoulder,  the 
head  of  the  humerus,  in  order  to  escape  from  its  socket,  must  be  made 
to  descend  more  or  less  downwards,  we  shall  reo:ard  this  dislocation 


534  DISLOCATION'S    OF    THE    SHOULDER. 

as  the  type  of  all  tlie  others,  and  shall  make  it  the  subject  of  especial 
consideration  as  well  as  of  reference  when  speaking  of  the  other  forms 
of  dislocation. 

Causes. — The  most  frequent  causes  of  this  accident  are  a  fall  from  a 
height,  in  which  the  patient  strikes  upon  the  top  of  the  shoulder,  or  a 
direct  blow  upon  the  same  point.  I  have  found  the  arm  dislocated  into 
the  axilla  by  one  or  the  other  of  these  causes  eight  times.  Three  times 
it  has  been  dislocated  by  a  blow  upon  the  outside  of  the  arm  near  its 
upper  end;  three  times  by  a  fall  upon  the  extended  hand;  once  by  a 
fall  upon  the  elbow,  and  in  this  latter  case  the  arm  was  probably  car- 
ried away  from  the  body  at  the  moment  of  the  receipt  of  the  injury. 

In  all  the  above  examples,  the  shoulder  has  been  dislocated  by 
the  simple  force  of  the  blow,  or  with  only  slight  aid  from  muscular 
action ;  but  in  a  considerable  number  of  cases  the  bone  is  displaced 
almost  wholly  by  the  action  of  the  muscles,  the  arm  having  been 
previously  violently  abducted  ;  and  perhaps  in  some  cases  the  capsule 
being  torn  before  the  resistance  of  the  overstrained  muscles  has 
accomplished  the  displacement.  Thus,  in  two  instances  I  have  known 
the  dislocation  to  result  from  holding  on  to  the  reins  after  being 
thrown  from  a  carriage ;  in  the  same  number  of  cases  the  patients 
have  fallen  through  a  hatchway  and  been  caught  and  suspended  under 
the  arms ;  once  a  woman  met  with  this  accident  by  holding  on  to  a 
pump  handle  when  she  had  slipped  and  fallen  upon  the  ice.  A  few 
years  since  I  examined  the  arm  of  a  Swiss  woman,  Maria  Norregan, 
who  was  then  sixty-five  years  old,  and  whose  humerus  had  been  dis- 
located into  the  axilla  seventeen  years  before,  where  it  still  remained. 
Her  own  account  of  the  accident  was,  that  she  was  returning  from  the 
Jura  Mountains,  near  Neufchatel,  with  a  load  of  hay  upon  her  head. 
She  had  carried  it  a  long  way  with  her  hands  held  upwards,  without 
once  stopping  to  rest,  and  when  at  length  she  threw  down  the  load  at 
her  door,  the  right  shoulder  was  dislocated.  The  arm  became  soon 
very  painful,  and  swollen  to  the  fingers'  ends ;  but  she  was  too  remote 
from,  and  too  poor,  to  employ  a  surgeon.  A  tailor,  who  used  to  do 
the  minor  surgery  of  the  neighborhood,  bled  her  three  or  four  times, 
but  the  dislocation  was  not  recognized  until  many  months  after. 

A  Mrs.  Hunn  informed  me  that  when  she  was  twenty-two  years 
old  she  had  a  convulsion,  and  that  her  attendants,  in  trying  to  hold 
her  upon  her  bed,  actually  pulled  the  shoulder  out  of  joint.  After 
the  first  accident  the  dislocation  was  not  repeated  for  four  years,  but 
since  then  it  had  occurred  from  very  slight  causes  many  times.  She 
was  in  the  habit  of  reducing  it  herself  by  placing  a  ball  in  the  axilla 
and  using  the  arm  as  a  lever. 

Dr.  Lehman  reports  the  case  of  a  sailor  on  board  an  American  brig, 
who  was  subject  to  a  dislocation  into  the  axilla  from  very  slight  causes, 
and  especially  if  he  bent  his  body  far  over  to  raise  anything.  He 
could  also,  by  pulling  horizontally,  remove  the  head  of  the  bone  from 
its  socket.  It  was  reduced  easily,  and  he  experienced  no  pain  either 
in  the  reduction  or  dislocation,  nor  indeed,  during  the  displacement.^ 

'  Leh.man,  Amer.  Journ.  Med.  Sci.,  vol.  i.  p.  242,  1828. 


DISLOCATION    OF    THE    SHOULDER   DOWNWARDS, 


535 


Dislocation  of  the  shoulder  downwards  into  the  ax- 
illa. (Subglenoid.) 


Pathology. — In  this  accident  the  head  of  the  bone  is  made  to  press 
against  the  capsule  below  and  immediately  in  front  of  the  long 
head  of  the  triceps,  until  the  p.     220 

capsule  gives  way,  and  con- 
tinuing to  descend  in  the  same 
direction  it  is  finally  arrested 
by  the  triangular  surface  of  the 
inferior  edge  of  the  scapula  im- 
mediately below  the  glenoid 
fossa.  Owing  to  the  pressure 
of  the  tendon  of  the  triceps  be- 
hind, it  occupies  a  position  also 
a  little  in  advance  of  the  centre 
of  this  triangle,  or  rather  upon 
its  anterior  edge,  so  that  it 
rests  more  or  less  upon  the 
belly  of  the  subscapularis  mus- 
cle. 

The  capsule  is  generally  torn 
quite  extensively,  especially  be- 
low and  in  front;  and,  contrary 
to  what  has  been  affirmed  by 
Sir  Astley  Cooper,  the  tendon 
of  the  long  head  of  the  biceps  is  often  broken  asunder  or  detached 
completely  from  its  insertion ;  the  supra-spinatus  muscle  is  stretched 
or  lacerated ;  the  infra-spinatus,  subscapularis  and  coraco-brachialis 
are  put  upon  the  stretch  ;  the  subscapularis  being  also  sometimes  com- 
pletely torn  from  its  attachment  to  the  head  of  the  humerus,  and  in 
either  case,  whether  torn  or  merely  compressed  and  stretched,  the  cir- 
cumflex nerve,  which  runs  along  its  lower  margin,  is  subject  to  severe 
injury;  the  deltoid  muscle  is  also  placed  in  a  condition  of  extreme 
tension  :  while  the  teres  major  and  minor  in  this  respect  are  subjected 
to  but  little  change. 

Symptoms. — A  palpable  depression  immediately  under  the  extremity 
of  the  acromion  process,  more  distinct  in  children,  in  very  old  and  in 
thin  people,  than  in  adults  of  middle  life  or  than  in  fat  or  muscular 
people,  but  never  absent  completely,  unless  the  shoulder  is  very  much 
swollen ;  the  elbow  carried  out  from  the  body  three  or  four  inches, 
sometimes  a  little  backwards,  and  the  line  of  its  axis  directed  toward 
the  axilla  ;  the  outer  surface  of  the  arm  presenting  two  planes  inclined 
toward  each  other,  and  meeting  at  the  point  of  insertion  of  the  deltoid 
muscle ;  the  head  of  the  humerus  felt  in  the  axilla,  particularly  when 
the  elbow  is  carried  away  from  the  body ;  numbness  of  the  arm,  ac- 
companied generally  with  pain,  especially  when  any  attempt  is  made 
to  press  the  elbow  against  the  side ;  rigidity  with  inability  to  move 
the  arm  freely  in  any  direction,  but  especially  inwards ;  allowing, 
however,  of  pretty  free  passive  motion,  but  not  permitting  the  elbow 
to  touch  the  body  without  great  pain,  which  pain  is  occasioned  mostly 
by  the  pressure  of  the  humerus  upon  the  axillary  plexus ;  under  no 
circumstances  can  the  hand  be  placed  upon  the  opposite  shoulder 


536 


DISLOCATIONS    OF    THE    SHOULDER. 


while  at  the  same  moment  the  elbow  touches  the  thorax ;  the  head  of 
the  patient,  and  sometimes  the  whole  body,  inclined  toward  the  in- 
jured arm ;  the  arm  lengthened  from  half  an  inch  to  an  inch;  a  chaf- 
ing or  friction  sound  is  not  unfrequently  present,  especially  if  the  bone 
has  been  some  days  dislocated ;  but  Mr.  Lawrence  mentions  a  case  in 
which  there  was  a  distinct  crepitus,  yet  there  was  no  fracture — Dr. 
Hays  saw  a  similar  case  in  Wills  Hospital,  Philadelphia,  in  a  woman 
sixty  years  old,  whose  arm  had  been  dislocated  forwards  eight  weeks.' 
Other  surgeons  have  related  like  examples,  but  it  is  probable  that  in 
all  these  cases  there  has  been  an  exposure  of  the  bone  at  or  near 
the  edge  of  the  glenoid  fossa,  by  the  partial  detachment  of  its  liga- 

Fig.  221. 


Dislocation  of  the  shoulder  downwards  into  the  axilla.     (Subglenoid). 


mentous  margin,  or  some  portion  of  the  head  has  become  divested  of 
its  cartilaginous  covering. 

Decisive  as  these  signs  usually  are  of  the  true  nature  of  the  accident, 
cases  will  every  now  and  then  occur  in  which  the  diagnosis  will  be 
attended  with  great  difficulty,  and  especially  if  a  few  hours  have  been 
permitted  to  elapse  since  the  occurrence  of  the  injury,  so  that  consid- 
erable effusions  of  blood  and  of  lymph  may  have  taken  place ;  while 
at  a  still  later  period,  when  the  swelling  has  subsided,  the  diagnosis 
again  becomes  easy.  "At  this  latter  period,"  says  Sir  Astley  Cooper, 
"it  is  that  surgeons  of  the  metropolis  are  usually  consulted  ;  and  if 
we  detect  a  dislocation  which  has  been  overlooked,  it  is  our  duty  in 
candor  to  state  to  the  patient  that  the  difficulty  of  detecting  the  nature 


'  Lawrence,  Hays,  Amer.  Journ.  Med.  Sci.,  voL  xxiv.  p,  236,  May,  1S39. 


I 


DISLOCATIOX    OF    THE    SHOULDER    DOWNWARDS,  537 

of  tlie  accident  is  exceedingly  diminished  by  tlie  cessation  of  inflam- 
mation, and  the  absence  of  tumefaction." 

It  has  never  happened  to  me  to  have  seen  a  case  of  dislocation  into 
the  axilla  which  was  not  easily  recognized,  nor  have  I  met  with  any 
cases  in  the  practice  of  other  surgeons,  but  in  my  report  to  the  New 
York  State  Medical  Society,  already  referred  to,  I  have  related  two 
cases  which  were  not  recognized  by  the  patients  themselves,  and  no 
surgeon  was  called  until  after  several  days  or  weeks,  and  three  cases 
in  which  empirics  having  been  employed  they  failed  to  detect  the  dis- 
location. Although,  therefore,  I  am  prepared  to  admit  the  justness  of 
the  observations  made  by  Sir  Astley  Cooper,  I  think  that  if  the  case 
is  seen  within  an  hour  or  two  after  the  accident,  its  nature  may  be 
generally  determined  promptly  by  the  surgeon  of  ordinary  experience; 
but  upon  this  subject  I  have  already  spoken  very  fully  in  the  chapter 
on  fractures  of  the  humerus ;  and  from  the  examples  and  opinions 
which  I  have  there  presented  it  will  be  inferred  that  it  is  much  more 
common  to  mistake  a  fracture  for  a  dislocation,  than  a  dislocation  for 
a  fracture,  an  observation  which  is  equally  as  applicable  to  dislocations 
forwards  as  to  the  form  of  dislocation  now  under  consideration. 

Prognosis. — If  the  force  which  displaced  the  bone  was  not  great,  or 
if  the  shoulder-joint  has  not  suffered  any  injury  from  the  accident 
itself  beyond  the  mere  rupture  of  the  capsule  and  a  moderate  strain- 
ing of  the  muscles,  and  if  the  dislocation  has  been  early  and  easily 
reduced,  the  patient  is  immediately  after  the  reduction  able  to  move 
the  arm  freely  in  all  directions ;  very  little  swelling  follows,  and  in  a 
short  time  a  perfect  restoration  of  all  the  functions  of  the  limb  is  ac- 
complished. 

It  cannot,  however,  always  be  inferred  from  the  degree  of  violence 
employed  in  the  production  of  the  dislocation,  nor  from  the  absence 
or  presence  of  swelling,  how  much  injury  the  tendons,  muscles,  and 
nerves  have  suffered,  since  the  same  causes  produce  greater  lesions  in 
one  person  than  in  another,  and  the  amount  of  swelling  may  depend 
upon  the  accidental  rupture  of  an  unimportant  bloodvessel,  or  upon 
some  peculiarity  in  the  constitution  of  the  patient  predisposing  to 
serous,  fibrous,  or  sanguineous  effusions. 

To  whatever  cause  we  may  find  occasion  to  attribute  the  result,  it 
will  nevertheless  be  observed  that  in  a  great  majority  of  cases  the  limb 
is  not  restored  to  all  its  original  strength  and  freedom  of  motion 
until  after  the  lapse  of  some  months ;  and  the  shoulder  does  not  re- 
sume its  perfect  form  and  symmetry  until  a  much  later  period  :  occa- 
sional pains,  especially  after  exercise  of  the  muscles,  and  in  certain 
conditions  of  the  weather,  are  present  also  at  irregular  intervals  and 
for  indefinite  periods  of  time.  Opposite  and  more  favorable  termina- 
tions must  be  regarded  as  exceptions  to  the  rule. 

Where  the  reduction  has  been  made  within  a  few  hours,  I  have 
found  the  shoulder  affected  with  muscular  anchylosis  with  more  or  less 
weakness  of  the  arm  after  a  lapse  of  from  a  few  days  to  one  and  two 
years. 

A  laborer,  set.  41,  had  dislocated  his  right  shoulder  into  the  axilla. 
Dr.  H.,  an  intelligent  young  surgeon,  reduced  the  bone  easily  with  his 


538  DisLocATioisrs  of  the  shoulder. 

hands  alone,  while  the  patient  was  still  unconscious  from  the  shock  of 
the  injury.  _  After  six  weeks  he  called  upon  me  accompanied  by  his 
surgeon,  thinking  that  it  was  not  properly  reduced  because  the  arm 
was  still  painful,  and  he  could  not  move  it  freely.  The  bone  was, 
however,  well  in  its  socket.  One  year  later  I  examined  this  man  and 
found  some  anchylosis  remaining  in  the  shoulder-joint, 

James  Rogers,  jet.  89,  fell  while  running  and  struck  upon  his  right 
shoulder.  Dr.  Eastman,  Prof,  of  Anatomy  in  the  Buffalo  Medical 
College,  reduced  the  dislocation  four  hours  after  the  occurrence,  in  the 
following  manner :  The  patient  being  seated  in  a  chair,  Dr.  Eastman 
placed  his  knee  in  the  axilla  and  manipulated,  while  one  assistant 
supported  the  acromion  process,  and  another  pulled  downwards  upon 
the  forearm.  The  time  occupied  in  the  reduction  was  about  two 
minutes,  and  the  bone  finally  resumed  its  position  with  a  snap  audible  to 
all  the  persons  in  the  room.  For  some  mouths  after,  and  at  the  period 
when  I  was  invited  to  see  him,  the  muscles  about  the  shoulder  were 
rigid,  and  the  motions  of  the  joint  embarrassed ;  but  at  the  end  of  two 
years.  Dr.  Eastman  informed  me  that  the  joint  had  become  free,  and 
the  arm  as  useful  as  before,  except  that  he  could  not  throw  a  stone. 

In  another  case,  a  gentleman  residing  in  an  adjoining  county,  get. 
42,  was  thrown  from  his  carriage,  falling  forwards  upon  his  hands. 
The  dislocation  was  reduced  promptly  by  placing  the  heel  in  the  axilla, 
and  within  fifteen  minutes  after  it  had  occurred.  Three  months  after 
this  the  patient  consulted  me  on  account  of  the  immobility  of  the 
shoulder-joint,  and  because  several  surgeons  had  expressed  a  doubt 
whether  it  was  properly  reduced.  The  anchylosis  was  then  so  com- 
plete that  the  humerus  could  not  be  moved  separately  from  the  scapula, 
but  there  was  no  displacement.  This  gentleman  again  called  upon 
me  at  the  end  of  four  years,  and  I  then  found  the  arm  nearly  restored 
to  its  priginal  condition,  but  it  was  not  quite  so  strong  as  before.  He 
experienced  also  "curious"  sensations  in  his  arm  and  hand  occasionally. 
The  anchylosis  had  continued  with  very  little  improvement  about  two 
years,  after  which  it  had  been  gradually  disappearing. 

1  need  scarcely  say  that  in  those  examples  in  which  the  reduction 
of  the  bone  has  been  delayed  beyond  a  few  hours,  or  for  several  days 
or  weeks,  the  continuance  of  the  anchylosis  has  been  more  persistent; 
but  in  no  case  which  has  come  under  my  observation,  unless  the  bone 
still  remained  unreduced,  has  the  anchylosis  been  permanent.  For 
this  reason  I  am  disposed  to  think  that  muscular,  rather  than  fibrous 
or  ligamentous  anchylosis,  is  the  cause,  generally,  of  the  immobility 
of  the  joint.  I  have  certainly  never  in  any  instance  met  with  a  true 
bony  anchylosis  as  a  consequence  of  a  shoulder  dislocation.  The  an- 
chylosis in  question  seems  to  be  a  result  simply  of  laceration,  or  more 
generally  of  a  severe  strain  of  the  muscular  fibres,  resulting  in  inflam- 
mation and  a  contraction  of  these  fibres ;  and  its  occurrence  in  any  par- 
ticular case  may  therefore  be  justly  attributable  either  to  the  position 
of  the  bone  when  it  is  dislocated,  to  the  force  of  the  blow  which  has 
produced  the  dislocation,  or  to  the  violence  applied  in  the  attempts  at 
reduction. 

Paralysis  and  wasting  of  the  muscles  of  the  arm,  either  with  or 


DISLOCATION    OF    THE    SHOULDER    DOWNWARDS.  539 

witTiout  muscular  contraction  and  rigidity,  are  also  observed  in  a  cer- 
tain number  of  cases.  Especially  has  it  been  noticed  that  the  deltoid  mus- 
cle is  liable  to  atrophy  ;  and  in  their  attempts  to  explain  the  frequency 
of  its  occurrence  in  this  latter  muscle,  surgeons  have  generally  referred 
to  a  probable  rupture  of  the  circumflex  nerve,  a  circumstance  which 
the  autopsies  show  does  occasionally  take  place;  or  to  a  mere  stretching 
of  this  nerve  ;  yet  it  is  quite  as  fair  to  presume  that  in  many  cases 
it  is  due  solely  to  the  greater  injury  which  the  deltoid  muscle  has 
sustained  by  the  unnatural  position  of  the  head  of  the  bone  during 
the  continuance  of  the  dislocation,  for,  with  the  exception  of  the  supra- 
spinatus,  it  is  placed  more  upon  the  stretch  than  any  other.  Nor  is  it 
improbable  that  in  some  cases  it  is  due  to  the  mere  force  of  the  blow 
which,  having  been  received  directly  upon  the  top  of  the  shoulder, 
has  contused  the  muscle.  In  short,  any  of  the  causes  which  may  de- 
termine in  the  deltoid  inflammation  and  consequent  rigidity,  must 
finally  result  in  desuetude  and  consequent  atrophy. 

In  quite  a  number  of  cases  my  attention  has  been  called  to  a  re- 
markable fulness  just  in  front  of  the  head  of  the  bone,  which  has  con- 
tinued sometimes  for  many  months  and  even  years  after  the  reduction 
has  been  effected,  the  patients  having  in  several  cases  applied  to  me 
to  know  whether  this  did  not  indicate  that  the  bone  was  not  in  its 
socket,  especially  as  it  has  been  usually  attended  with  some  stiffness  in 
the  joint.  Not  unfrequently  I  have  been  told  that  surgeons  who  had 
noticed  this  fulness,  thought  the  bone  was  not  reduced;  and  in  one 
instance  I  am  informed  that  a  jury  returned  a  verdict  against  the  sur- 
geon, where  there  was  no  other  evidence  of  malpractice  than  this  ful- 
ness with  some  anchylosis,  but  which,  in  the  opinion  of  these  gentle- 
men, was  conclusive  evidence  that  the  bone  was  not  properly  set. 
The  deception  is  also  often  the  more  complete  from  the  fact  that 
there  may  exist  a  corresponding  depression  underneath  the  acromion 
process,  behind. 

It  may  be  present  where  but  little  force  has  been  used,  either  in  the 
production  of  the  dislocation,  or  in  its  reduction.  I  have  seen  it  in  a 
girl,  only  fourteen  years  of  age,  who  had  dislocated  her  left  shoulder 
into  the  axilla,  by  a  fall  upon  a  slippery  side-walk.  I  reduced  the 
bone,  assisted  by  Dr.  George  Burwell,  of  this  city,  within  half  an  hour 
after  the  accident.  Dr.  Burwell  held  upon  the  acromion  process  while 
T  lifted  the  arm  to  a  right  angle  with  the  body,  and  pulled  gently,  and 
the  reduction  was  at  once  accomplished  ;  but  we  immediately  noticed 
that  the  head  of  the  bone  seemed  to  press  forwards  in  the  socket  so  as 
to  resemble  what  Sir  Astley  Cooper  has  described  as  a  partial  forward 
luxation.  There  was  also  a  corresponding  depression  behind.  Carry- 
ing the  elbow  back  rendered  the  projection  more  decided,  but  bringing 
it  forwards  would  not  make  it  entirely  disappear. 

In  other  instances  much  more  difficulty  has  been  experienced  and 
more  force  has  been  employed  in  the  reduction.  A  man  weighing  two 
hundred  pounds,  and  forty -one  years  of  age,  residing  at  Bath,  in 
Steuben  Co.,  fell  from  a  load  of  hay  in  May,  1853,  striking  upon  the 
top  and  front  of  the  left  shoulder.  It  was  immediately  ascertained 
ithat  he  had  dislocated  his  arm  into  the  axilla,  and  broken  his  leg.     A 


540  DISLOCATIONS    OP    THE    SHOULDERS 

young  surgeon  attempted  within  a  few  minutes  to  reduce  the  disloca- 
tion, but  failed ;  and  about  two  hours  later  it  was  reduced  by  another 
surgeon,  with  the  aid  of  chloroform  and  Jarvis's  adjuster.  Four  years 
after  the  accident  had  occurred,  this  gentleman  came  to  me  accom- 
panied by  the  surgeon  who  had  made  the  reduction,  in  consequence 
of  its  having  been  intimated  by  some  medical  men  that  it  was  not 
properly  reduced.  The  arm  was  not  as  strong  as  the  other ;  some 
anchylosis  existed  at  the  shoulder-joint;  but  especially  it  was  noticed 
that  there  still  remained  a  remarkable  fulness  in  front  as  if  the  head 
of  the  bone  was  pressed  forwards.  By  no  manipulation  or  position 
could  this  fulness  be  made  to  disappear,  yet  the  bone  was  plainly 
enough  in  its  socket. 

This  phenomenon  is  probably  due  in  some  cases  to  a  rupture  of  the 
supra-spinatus  muscle,  and  the  consequent  preponderating  action  of 
the  antagonizing  muscles,  or  to  the  laceration  of  the  capsule,  but  most 
often,  I  imagine,  to  a  rupture  or  to  a  displacement  of  the  long  head  of 
the  biceps,  a  circumstance  to  which  I  shall  more  particularly  allude 
under  the  subject  of  "  partial  dislocations." 

Among  the  results  of  this  dislocation  must  be  placed  a  tendency  to 
reluxation,  which,  although  it  may  not  often  be  made  manifest  by  its 
actual  occurrence,  owing  perhaps  to  the  prudence  of  the  surgeon,  yet 
it  does  take  place  in  a  sufficient  number  of  cases  to  establish  its 
peculiar  liability.  Indeed,  we  need  only  consider  how  imperfect  is 
the  protection  against  this  accident,  when  once  the  capsule  has  been 
torn,  to  appreciate  this  observation.  Examples  of  spontaneous  luxa- 
tion, or  of  luxation  of  the  shoulder  from  very  trivial  causes,  after  it 
has  once  been  luxated,  may  be  found  in  the  experience  of  almost 
every  surgeon.  I  have  myself  met  with  several  persons  who  have 
had  a  second  or  third  luxation  from  a  slight  cause,  and  in  some  in- 
stances, where  the  patients  were  subject  to  epilepsy,  the  luxations 
have  occurred  whenever  the  convulsions  returned. 

A  gentleman  residing  in  Toronto,  Canada  West,  had  a  dislocation 
of  the  right  shoulder  into  the  axilla  when  he  was  quite  a  child,  and 
the  accident  was  renewed  when  twenty-nine  years  old  by  falling  from 
a  carriage  head  foremost,  with  his  right  arm  extended  and  uplifted. 
Since  then  until  he  called  upon  me,  a  period  of  about  six  years,  he 
has  been  constantly  subject  to  the  same  dislocation ;  and  he  cannot 
raise  his  arm  high  above  his  shoulders  without  producing  a  sub-luxa- 
tion, the  head  of  the  humerus  resting  upon  the  outer  margin  of  the 
lower  and  anterior  edge  of  the  glenoid  fossa,  but  by  rotating  the  arm 
outwards  it  immediately  resumes  its  place.  I  found  the  whole  limb 
as  fully  developed,  and  he  said  it  was  quite  as  strong  as  the  opposite 
limb. 

I  have  already  mentioned  the  case  of  Mrs.  Hunn,  whose  arm  had 
been  dislocated  more  than  twenty  times  in  the  last  five  years;  and  I 
remember  a  lad,  Pat.  Dolan,  aged  nineteen  years,  whose  left  arm  was 
dislocated  by  falling  from  the  mast-head  of  a  vessel  and  hanging  by 
his  hand.  No  attempt  was  made  to  reduce  it  until  fourteen  hours 
after  the  accident,  at  which  time  it  was  set  by  two  German  doctors, 
but  not  until  they  had  pulled  upon  it  three  hours.     Four  months 


DISLOCATION    OF    THE    SHOULDER    DOWNWARDS.  541 

after  it  was  again  dislocated  by  the  slipping  of  an  oar  wliile  he  was 
rowing  a  boat.  A  surgeon  having  failed  this  time  to  bring  it  into 
place,  I  succeeded  readily  and  without  the  aid  of  an  anaesthetic,  by 
pulling  the  arm  directly  upwards  in  the  line  of  the  body,  while  ray 
foot  was  pressed  upon  the  top  of  the  scapula. 

We  have  referred  more  than  once  to  the  occasional  difficulty  of 
diagnosis  in  this  as  well  as  in  many  other  shoulder  accidents; 
and  I  have  alluded  to  five  cases  in  which  the  dislocation  was  not 
recognized,  but  none  of  them  had  been  seen  by  a  surgeon.  Other 
writers  have,  however,  mentioned  many  examples  of  unreduced  dis- 
locations of  the  shoulder,  for  which  surgeons  of  skill  and  experience 
were  responsible.  In  other  cases  the  dislocation  has  been  clearly 
made  out,  but  the  surgeon  has  been  unable  to  reduce  the  bone.  It 
has  been  my  fortune  to  succeed  in  several  instances  where  others 
have  made  a  fair  trial  and  have  failed,  but  the  following  case  leaves 
me  no  opportunity  to  boast  the  superiority  of  my  own  skill  above 
that  of  my  confrlres. 

Mary  Kanally,  set.  49,  a  large,  fat,  laboring  woman,  was  admitted 
into  the  Buffalo  Hospital  of  the  Sisters  of  Charity,  with  a  dislocation 
of  the  right  humerus  into  the  axilla,  which  had  occurred  twelve  hours 
before.  This  is  the  same  woman  of  whom  I  have  before  spoken  as 
having  produced  the  dislocation  by  a  fall  while  holding  upon  the 
handle  of  a  pump. 

Drs.  Lockwood  and  Baker,  of  this  city,  were  first  called,  and  attempted 
reduction.  They  made  extension  and  counter-extension  in  every 
possible  direction,  and  for  a  long  time,  but  to  no  purpose.  She  was 
then  sent  to  the  hospital.  Without  attempting  to  describe  minutely 
the  various  modes  of  extension  and  manipulation  which  I  employed, 
I  will  briefly  state  that  having  placed  her  completely  under  the 
influence  of  chloroform,  the  manipulations  were  made  assiduously 
during  one  hour  without  success.  On  the  following  morning  she 
was  bled  freely  from  the  opposite  arm,  and  chloroform  again  admi- 
nistered ;  extension  being  made  in  the  presence  of  Prof.  Charles  A. 
Lee  and  other  gentlemen,  with  Jar  vis's  adjuster.  After  more  than  an 
hour  the  effort  was  again  suspended.  On  the  following  day  we  made 
a  third  attempt;  the  patient  being  completely  under  the  influence  of 
chloroform,  but  with  no  better  success.  The  chloroform  produced  a 
condition  approaching  apoplexy,  and  it  was  not  again  used.  On  the 
tenth  day,  assisted  by  Prof.  James  P.  White  and  other  surgeons,  we 
applied  the  compound  pulleys,  moving  the  arm  in  various  directions. 
Twice  we  thought  the  reduction  was  accomplished,  but  as  often  as  we 
proceeded  to  examine  it  attentively  we  found  it  was  not.  If  it  did 
ever  actually  pass  into  the  socket,  it  was  immediately  displaced. 

The  woman  after  this  refused  to  submit  to  any  further  attempts,  and 
she  soon  left  the  hospital,  nor  have  I  seen  or  heard  from  her  since. 

Sir  Astley  Cooper  has  thus  described  the  appearances  presented  on 
dissection  of  a  dislocation  which  had  been  long  unreduced :  "  The  head 
of  the  bone  altered  in  its  form ;  the  surface  toward  the  scapula  being 
flattened.  A  complete  capsular  ligament  surrounding  the  head  of  the 
OS  humeri.     The  glenoid  cavity  entirely  filled  by  ligamentous  matter, 


542 


DISLOCATIONS    OF   THE    SHOULDER. 


Fig.  222. 


New  socket,  in  an  ancient  luxation  of 
the  shoulder  downwards.  (From  Sir  A. 
Cooper.) 


in  which  were  suspended  small  portions  of  bone,  which  were  of  new 
formation,  as  no   portion   of  the  scapula  or  humerus  was  broken. 

A  new  cavity  formed  for  the  head  of 
the  OS  humeri  on  the  inferior  costa  of 
the  scapula  (Fig.  222);  but  this  was 
shallow,  like  that  from  which  the  bone 
had  escaped." 

When  the  dislocation  into  the  axilla 
remains  unreduced,  the  consequences 
are  always  sufficiently  grave,  but  they 
differ  very  much  in  degree,  in  cha- 
racter, and  in  persistence,  according 
as  the  arm  has  remained  a  longer  or 
shorter  time  unreduced,  and  according 
to  the  presence  or  absence  of  complica- 
tions. These  conditions  will  be  best 
illustrated  by  a  reference  to  examples. 
Wm.  S.,  a  German,  get.  51,  fell 
down  a  flight  of  steps  while  intoxi- 
cated, producing  a  dislocation  of  the  left 
arm  into  the  axilla.  Eleven  hours  after 
the  accident,  he  was  received  into  the 
Buffalo  Hospital  of  the  Sisters  of  Charity.  No  attempt  had  been  made 
to  reduce  the  bone.  The  reduction  was  effected  by  myself  with  tolera- 
ble ease,  by  extending  the  arm  perpendicularly  above  the  head,  while 
my  foot  pressed  upon  the  top  of  the  scapula.  The  head  of  the  hume- 
rus could  be  plainly  felt  in  the  axilla  approaching  the  socket,  until  it 
seemed  to  be  directly  over  it,  when,  on  lowering  the  arm,  it  was  found 
to  be  reduced.  After  the  reduction,  the  patient  could  not  raise  the  arm 
more  than  eight  inches  from  the  body.  The  fingers,  hand,  and  fore- 
arm were  almost  paralyzed.  Three  weeks  later,  when  he  left  the  hos- 
pital, his  arm  had  improved,  but  he  could  not  flex  his  fingers. 

Mrs.  G.,  get.  70,  fell  down  a  flight  of  steps  and  dislocated  her  arm 
into  the  axilla.  She  did  not  suspect  the  nature  of  the  injury,  and  no 
surgeon  was  called.  I  was  consulted  one  week  after  the  accident,  at 
which  time  she  was  suffering  great  pain  from  the  pressure  of  the  head 
of  the  bone  upon  the  axillary  nerves.  We  first  attempted  to  reduce 
the  bone  by  resting  the  knee  in  the  axilla  while  she  was  sitting,  bat 
without  success.  We  then  placed  her  in  bed,  and  with  my  knee  in 
the  axilla,  the  acromion  process  being  supported  by  the  hands  of  an 
assistant,  we  restored  the  bone  after  a  few  moments,  of  pretty  firm  ex- 
tension downwards  and  outwards.  After  the  reduction  she  could  not 
raise  her  arm,  but  the  pain  was  much  abated.  One  month  later,  the 
arm  remained  very  weak.  She  could  not  raise  it  more  than  six  inches 
toward  her  head,  but  I  could  raise  it  to  a  right  angle  with  the  body 
without  causing  pain.  The  whole  hand  felt  numb,  and  was  occasion- 
ally painful.  The  deltoid  muscle  was  slightly  atrophied.  There  was 
also  a  slight  flatness  under  the  acromion  process  behind,  and  on  the 
outer  side,  with  a  corresponding  fulness  in  front. 

Mary  Ann  Hasler,  get.  47,  was  admitted  to  the  hospital  with  a  dis- 


DISLOCATION    OF    THE    SHOULDER    DOWNWAEDS.  543 

location  of  tlie  right  humerus  into  the  axilla.  The  arm  had  been 
dislocated  three  weeks  in  consequence  of  a  fall  upon  the  upper  and 
outer  part  of  the  shoulder.  An  empiric,  who  saw  it  fifteen  minutes 
after  the  fall,  and  when  the  arm  was  not  swollen,  said  it  was  not 
dislocated.  On  the  fifth  day,  a  Catholic  clergyman  discovered  that  it 
was  out,  and  attempted  to  reduce  it,  but  was  not  successful.  When 
she  came  under  my  notice,  the.  arm  was  lengthened  about  one-quarter 
or  one-half  of  an  inch,  and  hung  out  from  the  body  in  a  condition  of 
almost  complete  paralysis.  There  was  very  little  "swelling  about  the 
shoulder  or  arm,  and  the  head  of  the  bone  could  be  distinctly  felt  in 
the  axilla.  The  patient  being  rendered  partially  insensible  by  chloro- 
form, I  placed  my  heel  in  the  axilla,  and  by  pulling  moderately  about 
thirty  seconds  in  a  direction  slightly  outwards  from  the  line  of  the 
body,  the  bone  was  reduced.  Seven  days  after  the  reduction,  she  left 
the  hospital,  the  arm  being  yet  quite  useless,  though  not  greatly  swol- 
len.   There  was  also  a  striking  fulness  in  front  of  the  head  of  the  bone. 

Wm,  Gardener,  of  Painted  Post,  N.  Y.,  set.  75,  dislocated  the  right 
humerus  into  the  axilla  twenty  years  before  I  saw  him  by  falling 
upon  his  hands  with  his  arms  extended.  I  found  the  arm  weak  and 
atrophied,  so  that  he  could  raise  it  but  slightly  outwards  from  his 
side ;  he  was  unable  to  move  it  forwards  much  beyond  the  line  of  his 
body,  but  he  could  carry  it  back  quite  freely.  The  whole  hand  was 
in  a  condition  of  partial  insensibility. 

I  have  before  mentioned  the  case  of  Maria  Norrigan,  the  Swiss 
woman,  whose  arm  had  been  dislocated  downwards  seventeen  years. 
The  deltoid  muscle  has  become  greatly  wasted;  the  head  of  the  bone 
can  be  felt  obscurely  in  the  axilla ;  the  arm  is  shortened  perceptibly ; 
the  elbow  hangs  freely  against  the  side ;  the  little  and  ring  fingers  are 
numb,  and  also  one-half  of  the  forearm ;  the  whole  hand  and  arm  are 
weak  and  atrophied  ;  she  complains  also  occasionally  of  a  troublesome 
sensation  of  formication  over  the  arm  and  hand  ;  she  cannot  straighten 
her  fingers  perfectly ;  the  elbow  may  be  raised  from  the  side  to  a  right 
angle  with  the  body,  but  she  cannot  raise  it  herself  more  than  one 
foot ;  she  carries  it  back  a  little  more  freely  than  forwards. 

In  compound  dislocations,  the  prognosis  must  always  be  regarded  as 
exceedingly  grave.  In  the  only  example  which  has  come  under  my 
notice,  the  circumstances  attending  which  I  shall  hereafter  mention  in 
the  general  chapter  devoted  to  compound  dislocations,  the  patient  died 
from  sloughing  of  the  axillary  artery.  Mr.  Scott  has,  however,  reported 
a  case,  in  a  boy  fourteen  years  of  age,  who  recovered  rapidly  after  the 
reduction  was  effected,  and  in  thirteen  months  his  arm  was  nearly  as 
useful  as  before.^ 

Treatment. — The  principles  of  treatment  in  this  dislocation  aie 
very  simple  and  easy  to  be  comprehended.  I  speak  now  of  recent 
uncomplicated  cases  of  dislocation  into  the  axilla ;  and,  notwithstand- 
ing the  various  and  sometimes  almost  contradictory  views  which  sur- 
geons have  entertained  as  to  the  best  and  most  rational  modes  of 

•  Scott,  Amer.  Journ.  of  Med.  Sci.,  voL  xx.  p.  515,  Aug.  1837,  from  the  London  Lan- 
cet for  March  4,  1837. 


544  DISLOCATIONS    OF    THE    SHOULDER. 

procedure,  I  continue  to  affirm  that  the  laws  which  are  to  govern  the 
reduction  in  a  great  majority  of  cases  are  established  and  indisputable. 

Observe  now  the  obvious  anatomical  facts,  and  then  consider  the 
inevitable  inferences. 

The  capsule  is  torn,  generally  extensively,  along  the  inner  and  lower 
margins  of  the  socket.  The  head  of  the  bone  is  lodged  below  and 
slightly  in  advance  of  its  natural  position,  in  consequence  of  which  the 
points  of  origin  and  insertion  of  the  deltoid  muscle  and  the  supra- 
spinatus  are  separated  somewhat  and  their  fibres  rendered  tense,  inso- 
much that  the  arm  is  abducted  and  actually  lengthened. 

At  first,  and  in  the  most  simple  cases,  these  are  the  only  muscles 
which  are  in  a  state  of  extreme  tension,  but  after  the  lapse  of  a  few 
hours,  or  of  a  few  days,  nearly  all  the  other  muscles  about  the  joint, 
most  of  which  were  originally  only  in  a  condition  of  moderate  exten- 
sion, and  some  of  which  were  rather  relaxed  than  extended,  sympathize 
with  those  which  are  suffering  the  most,  and  a  general  contraction  and 
rigidity  ensue,  increased  also  at  the  last  by  the  supervention  of  inflam- 
mation and  its  consequences. 

What,  from  these  simple  premises,  must  be  the  obvious  practical 
deductions  ? 

That  in  the  simplest  forms  of  the  dislocation  the  most  rational  mode 
of  reduction  will  be  to  elevate  the  arm  sufficiently  to  relax  the  over- 
strained deltoid  and  supra-spinatus  muscles,  which  bind  the  head  of 
the  hone  in  its  new  position,  and  to  pull  gently  in  the  same  direction, 
in  order  to  overcome  the  moderate  resistance  offered  by  several  other 
muscles,  but  whose  tension  cannot  be  relieved  by  the  same  manoeuvre. 

Failing  in  this,  that  we  shall  increase  the  relaxation  of  the  first 
named  muscles  by  pulling  at  a  right  angle  with  the  body,  or  even 
directly  upwards;  and  in  the  meanwhile,  as  we  carry  the  arm  more 
and  more  upwards  we  shall  operate  more  powerfully  against  the  re- 
sistance of  the  other  muscles. 

If  in  all  these  modifications  of  the  same  procedure,  we  keep  the 
arm  a  little  back  of  the  axis  of  the  body,  we  shall  accomplish  the  in- 
dications the  most  perfectly. 

Such  are  the  conclusions  which  must  be  drawn  from  the  anatomical, 
or,  as  Mr,  Pott  would  call  it,  the  "physiological"  argument;  and  which 
assumes  as  its  basis  that  the  muscles  constitute  the  sole  or  the  main 
obstacle  to  the  return  of  the  bone  to  its  socket.  If  any  surgeon  main- 
tains that  the  premise  is  unsound,  and  that  the  restoration  of  the  head 
of  the  bone  is  opposed  by  the  untorn  fibres  of  the  capsule  or  by  any 
other  important  circumstance  than  the  action  of  the  muscles  (we  speak 
of  ordinary  cases),  we  shall  content  ourselves  by  referring  him  again 
to  the  extensive  laceration  which  this  capsule  generally  suffers,  and 
to  the  constrained  and  almost  uniform  position  of  the  arm,  as  a  suffi- 
cient reply  to  his  objection. 

It  must  not  be  forgotten  that  in  all  these  modes  of  extension,  for 
with  all  of  them  some  slight  degree  of  extension  is  found  necessary, 
there  must  be  afforded  some  point  of  resistance  beyond  the  bone ;  and 
this  it  is  really  which  has  constituted  one  of  the  greatest  impediments 
to  reduction.     It  is  not  that  the  muscles  are  in  such  an  extraordinary 


DISLOCATION    OF    THE    HUMERUS    DOWNWARDS.  545 

State  of  extension  or  rigidity  that  they  must  be  operated  against  with 
great  force;  it  is  not  that  the  margin  of  the  glenoid  fossa  is  an 
elevated  barrier,  like  the  margin  of  the  acetabulum,  over  which  the 
bone  must  be  lifted  before  it  can  fall  into  its  socliet;  but  the  explana- 
tion^of  the  difficulty  so  often  experienced  in  producing  effective  ex- 
tension and  counter-extension  is  to  be  sought  for  mainly  in  the  fact 
that  the  scapula,  upon  which  the  humerus  rests,  is  movable,  being 
held  to  the  body  by  little  else  than  muscles,  which,  in  fact,  bind  the 
scapula  much  less  firmly  to  the  body  than  the  muscles  of  the  shoulder 
now  bind  the  scapula  to  the  arm;  while  at  the  same  time  the  scapula 
itself  presents  very  few  points  against  which  a  counter-extending  force 
can  be  properly  and  efficiently  applied. 

Occasionally  it  will  be  only  necessary  to  elevate  the  arm  to  an  acute 
angle,  or  to  a  right  angle  with  the  body,  when,  the  resistance  of  the 
deltoid  and  supra-spiuatus  being  overcome,  the  bone  will  at  once  re- 
sume its  place.  In  several  instances  which  have  come  under  my  notice 
nothing  more  has  been  necessary;  and  where  it  can  be  done,  the  least 
possible  pain  and  injury  are  inflicted.  It  is  the  method,  therefore, 
which  in  all  recent  cases  I  have  first  tried  and  would  wish  to  recom- 
mend. By  it  I  have  more  than  once  succeeded  when  other  and  more 
violent  efforts  had  failed. 

At  other  times  it  will  be  necessary  to  add  to  this  simple  manipula- 
tion only  a  moderate  degree  of  extension,  such  as  the  hands  of  the 
surgeon  can  make,  without  the  application  of  direct  counter-extension 
except  what  is  effected  by  the  weight  and  resistance  of  the  body. 

If,  however,  the  bone  refuses  to  move,  we  shall  then  be  obliged  to 
consider  upon  what  point  and  by  what  means  we  can  best  apply  a 
counter-extending  force.  Ample  experience  has  taught  me  that  the 
extremity  of  the  acromion  process  is  the  only  available  point  when 
we  are  making  the  extension  in  a  line  below  a  right  angle,  or  in  a 
line  downwards  more  or  less  approaching  the  axis  of  the  body.  It 
has  been  supposed  that  the  counter-extension  could  be  made  in  the 
axilla  against  the  inferior  margin  of  the  scapula;  but  several  obstacles 
are  presented  to  the  successful  application  of  force  at  this  point.  The 
axillary  space  is  narrow  and  deep,  so  that  even  with  the  ingenious 
contrivance  of  placing  first  a  ball  of  yarn  in  the  axilla,  and  upon  this 
the  heel  of  the  operator,  it  will  be  found  exceedingly  difficult  to  enter 
the  axilla  without  at  the  same  time  pressing  with  considerable  force 
against  its  muscular  margins ;  but  to  press  upon  the  pectoralis  major 
and.  latissimus  dorsi  is  to  neutralize  our  own  efforts.  If,  however, 
the  heel  or  the  ball  does  press  fairly  into  the  axilla,  it  will  not  find 
the  scapula  readily,  but  it  must  impinge  first  upon  the  head  of  the 
humerus,  which  is  always  a  little  to  the  inner  side  of  the  scapula.  If 
it  ever  is  made  to  reach  actually  the  inferior  border  of  the  scapula, 
and  I  do  not  think  it  is,  the  effect  must  be  still  only  to  tilt  the  scapula 
upon  itself  by  throwing  back  its  lower  angle,  and  not  to  separate  the 
glenoid  cavity  or  its  upper  and  anterior  margin  from  the  head  of  the 
humerus. 

AVhatever  success,  therefore,  may  have  attended  this  mode  of  prac- 
tice, either  in  my  own  hands  or  in  the  hands  of  other  surgeons,  must 
35 


546  DISLOCATION'S    OF    THE    SHOULDEE. 

be  ascribed,  not  to  the  counter-extension  thus  effected,  but  simply  to 
the  operation  of  the  heel  as  a  wedge,  which,  by  insinuating  itself 
between  the  body  and  the  head  of  the  bone,  has  thrust  it  outwards  and 
upwards  into  its  socket;  or  to  its  having  acted  as  a  fulcrum  upon 
which  the  humerus  has  operated  as  a  lever. 

It  is  to  the  extremity  of  the  acromion  process,  then,  that  we  must 
apply  our  counter-extension  when  we  are  employing  this  mode  of 
extension.  The  fingers  or  hands  of  a  faithful  assistant  may  answer 
the  purpose,  or,  having  removed  his  boot,  the  operator  may  often 
press  successfully  with  the  ball  of  his  foot,  and  the  more  he  carries  the 
arm  outwards  the  more  secure  will  be  his  seat  upon  the  process;  or 
we  may  adopt  some  of  the  contrivances  for  securing  the  process 
which  have  been  suggested  by  other  surgeons;  such  as  a  band  cross- 
ing the  shoulder,  and  made  fast  to  a  counter- band,  which  passes  through 
the  armpit  and  against  the  side  of  the  body.  Dr.  Physick,  of  Phila- 
delphia, reduced  a  dislocation  in  this  way  as  early  as  the  year  1790, 
in  the  case  of  a  patient  admitted  to  St.  George's  Hospital,  in  London, 
while  he  was  a  student  of  medicine,  and  he  subsequently  taught  the 
same  in  his  lectures.  Physick  directed  that  an  assistant  should  press 
firmly  against  the  process  with  the  palm  of  his  hand.  Dorsey  and 
Hays  approve  of  the  same  method,^  and  perhaps  a  majority  of  Ame- 
rican surgeons  regard  it  favorably. 

If  we  pull  directly  outwards,  at  a  right  angle  with  the  body,  we 
may  still  continue  to  press  upon  the  acromion  process  with  the  foot; 
or  we  may  perhaps  trust  to  the  method  of  making  counter-extension 
first  suggested  by  Nathan  Smith,  of  New  Haven. 

Dr.  Smith  exclaims:  "  What  surgeon  of  experience  has  not  encoun- 
tered the  difficulty  which  almost  always  occurs  in  fixing  the  scapula?" 
and  then  proceeds  to  explain  how  difficult  it  has  been  found  to  hold 
securely  even  upon  the  acromion  process  by  either  the  fingers  of  an 
assistant  or  the  split  band,  and  concludes  by  stating  what  seems  to 
him  the  most  effectual  mode  of  rendering  the  scapula  immobile, 
namely,  to  make  the  counter-extension  from  the  opposite  wrist.  By 
this  method  the  trapezii  are  provoked  to  contraction,  and  the  scapula 
of  the  injured  side  is  drawn  firmly  toward  the  spine  and  the  opposite 
scapula.  In  illustration  of  the  value  of  this  procedure  he  relates  the 
case  of  a  gentleman  who  had  suffered  a  dislocation  of  his  left  shoulder, 
and  upon  whom  an  unsuccessful  attempt  at  reduction  had  already 
been  made  by  a  respectable  surgeon.  Dr.  Smith  being  called,  pro- 
ceeded as  follows:  Two  gentlemen  made  counter-extension  from  the 
opposite  wrist,  while  Dr.  Smith  and  Dr.  Knapp  made  extension  from 
the  wrist  of  the  injured  side,  at  first  pulling  it  downwards,  but  gradu- 
ally raising  it  to  the  horizontal  direction,  and  then  gently  depressing 
the  wrist.  On  the  effort  being  steadily  continued  for  two  or  three 
minutes,  the  bone  was  observed  to  slip  easily  into  its  place.  This 
gentleman  subsequently  informed  Dr.  Smith  that  this  procedure  gave 
him  much  less  pain  than  that  adopted  by  the  first  surgeon.^ 

'  Physick,  Amer.  Joum.  Med.  Sci.,  vol.  xix.  p.  386,  Feb.  1837.  Dorsey's  Elements 
of  Surgery,  vol.  i.  p   214.     Philadelphia,  1813. 

^  Nathan  Smith,  Med.  and  Surg.  Memoirs,  1831,  p.  337. 


DISLOCATION    OF    THE    HUMERUS    DOWNWAEDS.  547 

But  no  position  places  the  scapula  so  completely  under  our  control 
as  that  in  which  the  arm  is  carried  directly  upwards  and  the  foot  is 
placed  upon  the  top  of  the  scapula.  By  this  method  we  may  succeed 
generally  when  every  other  expedient  has  failed,  yet  it  is  painful,  and 
I  cannot  but  think  that  it  increases  the  laceration  of  the  capsule,  and 
does  sometimes  serious  injury  to  the  muscles  about  the  joint.  La  Mothe 
was  the  first  to  recommend  this  method,^  but  as  early  as  the  year  1764, 
Charles  White,  of  Manchester,  made  fast  a  set  of  pulleys  in  the  ceiling, 
and,  placing  a  band  around  the  wrist  of  the  dislocated  arm,  he  drew 
the  patient  up  until  the  whole  body  was  suspended.  No  pressure, 
however,  was  made  upon  the  scapula  from  above,  which  is  no  doubt 
the  most  essential  part  of  the  process.^  By  La  Mothe's  plan,  Jobert 
succeeded  after  twenty-three  days  when  all  the  usual  methods  had 
failed.^  Sometimes  this  procedure  is  modified  by  placing  the  hand 
of  the  operator  against  the  top  of  the  scapula,  as  is  shown  in  the 
accompanying  drawing. 

Fig.  223. 


La  Mothe's  method,  modified. 

A  gentle  movement  backwards  or  forwards,  a  slight  rotation  of  the 
limb,  or  suddenly  dropping  the  arm  toward  the  body,  diverting  the 
attention  of  the  patient,  are  little  tricks  of  the  operator,  which  now 
and  then  prove  successful. 

Sir  Astley  Cooper  thus  describes  his  method  of  applying  the  heel 
to  the  axilla  (Fig.  224)  :— 

"  The  patient  should  be  placed  in  the  recumbent  posture  upon  a 
table  or  sofa,  near  to  the  edge  of  which  he  is  to  be  brought;  the 
surgeon  then  binds  a  wetted  roller  round  the  arm  immediately  above 
the  elbow,  upon  which  he  ties  a  handkerchief;  then  he  separates  the 
patient's  elbow  from  his  side,  and,  with  one  foot  resting  upon  the 
floor,  he  places  the  heel  of  his  other  foot  in  the  axilla,  receiving  the 
head  of  the  os  humeri  upon  it,  whilst  he  is  himself  in  the  sitting 
posture  by  the  patient's  side.  He  then  draws  the  arm  by  means  of 
the  handkerchief,  steadily,  for  three  or  four  minutes,  when,  under 

1  La  Mothe,  Am.  Joum.  Med.  Sci.,  vol.  xix.  p.  387,  Nov.  1836,  from  Melanges  de 
Med.  et  Chir.,  Paris,  1812. 

2  C.  White,  Ibid.,  from  Med.  Obs.  and  Inc^uiries,  vol.  ii.  p.  273,  London,  1764. 
»  Ibid.,  vol.  xxiii.  p.  237,  Nov.  1838. 


648 


DISLOCATIONS    OF    THE    SHOULDER. 


common  circumstances,  tlie  head  of  the  bone  is  easily  replaced;  but 
if  more  force  be  required,  the  handkerchief  may  be  changed  for  a  long 

Fig.  224. 


Sir  Astley  Cooper's  method  of  applying  extension  witli  the  heel  in  the  axilla. 

towel,  by  which  several  persons  may  pull,  the  surgeon's  heel  still 
remaining  in  the  axilla.  I  generally  bend  the  forearm  nearly  at  right 
angles  with  the  os  humeri,  because  it  relaxes  the  biceps,  and  conse- 
quently diminishes  its  resistance." 

He  was  also  accustomed  in  some  cases  to  reduce  the  dislocation  by 
substituting  the  knee  for  the  heel.  (Fig.  225.)   Placing  the  patient  upon 

a  low  chair,  the  axilla  is  laid  over  the 
knee  of  the  operator,  and  while  one 
hand  steadies  the  acromion  process  and 
scapula,  the  other  presses  downwards 
upon  the  lower  end  of  the  humerus. 

If  some  hours  or  days  have  elapsed 
since  the  occurrence  of  the  dislocation, 
it  will  be  necessary  to  resort  to  chlo- 
roform or  ether  for  the  purpose  of 
paralyzing  the  muscles,  as  well  as 
with  the  view  of  preventing  pain,  and 
it  may  be  necessary,  in  addition,  to 
resort  to  pulleys,  or  to  some  similar 
permanent  mode  of  extension.  The 
same  measures  also  sometimes  become 
necessary  in  very  recent  cases,  espe- 
cially in  muscular  subjects. 

In  employing  the  pulleys  we  gene- 
rally operate  not  exactly  in  a  line 
with  the  axis  of  the  body,  nor  above 
a  right  angle,  but  between  an  angle 
of  45°  and  a  right  angle. 

Mr.  Skey  has  suggested  a  plan  by 
which  we  may  combine  the  principle  of  the  heel  in  the  axilla  with 


Sir  Astley  Cooper's  method  of  operating 
with  the  knee  in  the  axilla. 


DISLOCATION    OF    THE    HUMEEUS    DOWNWAEDS. 


549 


the  pulleys,  but  which  plan  would,  in  my  judgment,  be  very  much 
improved  by  a  counter-extendiag  force  applied  to  the  acromion  pro- 
cess. I  ought  to  say,  however,  that  Mr.  Skey  prefers  that  the  scapula 
should  not  be  fixed,  believing  that  the  reduction  is  much  more  easily 
eflected  when  the  glenoid  cavity  is  drawn  downwards  in  the  act  of 
making  the  extension. 

^Yith  all  respect  for  the  opinion  of  this  distinguished  surgeon,  we 
cannot  precisely  agree  with  him,  and  while  we  would  be  disposed  to 
recommend  in  some  cases  a  trial  of  his  method  of  applying  the  pulleys, 
we  would  at  the  same  time,  or  certainly  in  the  event  of  its  failure,  add 
the  acromial  support,  and  especially  would  we  advise  that  the  arm 
should  be  more  abducted.  The  following  is  Mr.  Skey's  method,  as 
described  by  himself: — 

"  There  is  no  reason  why,  in  very  muscular  subjects,  or  in  old 
dislocations,  the  same  principle  may  not  be  applied  conjointly  with 
the  use  of  pulleys.  For  the  purpose  of  retaining  this  admirable, 
because  most  efficient  principle,  I  employ  a  well-padded  iron  knob, 
which   may  represent   the   heel,  from  which  there   extend  laterally 

Fig.  226. 


i 


Iron  knob  employed  by  Skey,  instead  of  the  beel. 

two  strong  straight  branches  of  the  same  metal,  each  ending  in  a  bulb 
or  ring  of  about  four  inches  in  length,  the  office  of  which  is  designed 
to  keep  the  margins  of  the  axilla  as  free  from  pressure  as  possible." 
The  iron  knob  is  to  be  pressed  well  up  into  the  axilla  and  attached  to 
cords  fastened  to  a  staple  ;  the  patient  lying  upon  his  back  or  inclined 
a  little  to  the  opposite  side.  The  arm  is  then  to  be  drawn  downwards 
by  the  pulleys,  "  as  nearly  as  possible,  parallel  to,  and  in  contact  with 
the  body."i 

Fig.  227. 


Skey's  method  of  making  extension  and  connter-extension  -ndtli  pulleys. 
'  Skey,  Operative  Surgery,  Amer.  ed.,  p.  93. 


550 


DISLOCATIOlSrS    OF   THE    SHOULDER. 


In  this  way  Mr.  Skey  says  that  he  has  succeeded  in  reducing  a 
great  many  dislocations,  whether  occurring  in  very  muscular  men,  or 
after  some  days',  or  weeks',  or  even  months'  duration ;  and  he  thinks 
the  plan  especially  applicable  to  cases  which  require  long  and  per- 
sistent extension. 

Mr.  Skey  and  many  other  surgeons  prefer  to  make  the  extension 
from  the  hand.  I  have  succeeded  as  well,  and  it  has  seemed  to  be 
less  painful  to  my  patients,  when  I  have  followed  the  practice  of  Sir 
Astley,  and  made  the  extension  from  the  arm.  Sir  Astley  always 
made  the  extension  more  or  less  out  from  the  line  of  the  body,  and 
generally  almost  at  a  right  angle  when  using  the  pulleys,  tiie  scapula 
being  made  fast  by  "  a  girt  buckled  on  the  top  of  the  acromion,"  or  by 
a  split  cloth,  as  in  the  accompanying  drawing. 

Fig.  228. 


Sir  Astley  Cooper's  mode  of  making  extension  with  the  pulleys. 

The  instrument  invented  by  Dr.  Jarvis,  of  Portland,  Conn.,  called  the 
adjuster,  useless  and  even  mischievous  as  we  have  found  it  in  its  appli- 
cation to  the  treatment  of  fractures,  possesses  considerable  merit  as  an 
apparatus  for  reducing  old  dislocations,  especially  of  the  shoulder.  The 
principal  advantage  which  may  be  claimed  for  it  is  that  while  the  forces 
are  being  applied  the  limb  may  be  moved  pretty  freely  in  all  direc- 
tions; thus  enabling  us  to  employ  rotation  at  the  same  time  that  the 
extension  is  made.  We  may  also  lift  or  depress,  adduct  or  abduct 
the  limb  without  relaxing  the  extension.  In  the  hands  of  American 
surgeons,  it  has  occasionally  been  successful  when  other  means  have 
failed.  Dr.  Jarvis  has  related  a  case  presented  at  the  Marine  Hos- 
pital, at  Mobile,  Tenn.,  of  forty-two  days'  standing,  which  he  reduced 
on  the  second  attempt  after  other  means  had  failed,^  and  Dr.  May,  of 
Washington,  reduced  a  similar  dislocation  at  the  end  of  six  weeks, 

'  Boston  Med.  and  Surg.  Journ.,  vol.  xxxix.  p.  215. 


DISLOCATION    OF    THE    HUMERUS    DOWN"\rARDS.  551 

by  the  same  apparatus,  without,  however,  having  previously  resorted 
to  any  other  means.^ 

I  have  myself  used  the  apparatus  occasionally,  both  in  my  hospital 
and  private  practice,  and  can  speak  favorably  of  its  operation. 

Ancient  Luxations. — Finally,  I  ought  to  speak  somewhat  more  in 
detail  of  the  manner  of  procedure,  and  of  the  principles  involved  in 
the  reduction  of  old  dislocations,  or  of  dislocations  requiring  the  inter- 
position of  mechanical  appliances;  especially  with  a  view  to  the  more 
complete  exposition  of  my  own  practice  in  these  cases. 

If  the  dislocation  is  recent,  but  reduction  is  found  impossible  with- 
out the  aid  of  mechanical  apparatus,  the  dif&culty  will  be  understood 
to  consist  mainly,  if  not  altogether,  in  the  resistance  offered  by  the 
muscles.  If,  in  a  few  exceptional  cases,  the  capsule,  or  an  untorn 
tendon,  or  the  margin  of  the  glenoid  fossa,  present  themselves  as 
obstacles,  they  must  still  be  considered  as  unusual  and  extraordinary 
impediments,  the  existence  of  which  may  be  regarded  rather  as  possible 
than  probable. 

Almost  our  sole  purpose  then,  it  will  be  understood,  in  all  recent 
cases  requiring  mechanical  appliances,  and  in  some  ancient  cases,  is  to 
overcome  the  contraction  of  the  muscles. 

We  prefer  always  to  place  the  patient  upon  a  mattress  laid  upon 
the  floor;  two  silk  handkerchiefs,  or  two  pieces  of  a  cotton  roller,  are 
then  laid  along  the  radial  and  ulnar  sides  of  the  humerus,  and  over 
the  middle  of  these,  immediately  above  the  condyles,  a  wetted  roller 
is  applied,  its  end  being  made  fast  with  a  needle  and  thread  rather 
than  with  a  pin.  The  upper  ends  of  the  longitudinal  strips,  or  of  the 
handkerchiefs,  are  now  turned  down  and  tied  to  the  opposite  ends, 
thus  converting  them  both  into  lateral  loops.  For  the  purpose  of 
making  counter- extension,  a  sheet  is  passed  around  the  body  under 
the  axilla,  and  made  fast  to  a  staple ;  while  an  intelligent  assistant  is 
to  manage  the  scapula  with  his  naked  hands,  either  by  pulling  with 
his  fingers  placed  under  the  process,  or  by  pushing  with  the  palm  of 
his  hand  and  ball  of  his  thumb.  The  pulleys,  secured  to  a  staple 
exactly  opposite  to  that  which  holds  the  counter-extending  band,  are 
made  ready,  but  not  for  the  present  attached  to  the  arm. 

As  soon  as  the  patient  is  placed  completely  under  the  influence 
of  an  anassthetic,  the  operator  is  ready  to  proceed  with  the  reduc- 
tion. It  is  my  maxim  never  to  attempt  to  accomplish  by  complicated 
and  violent  measures,  what  may  be  done  as  well  by  more  simple 
and  gentle  means.  I  think  it  proper,  therefore,  to  make  several  attempts 
at  reduction  by  manipulation  alone,  aided  now  by  the  anaesthetic,  the 
extending  and  counter-extending  bands,  &;c.,  before  resorting  to  the 
pulleys.  Seating  himself  upon  the  mattress,  with  his  boots  drawn, 
the  surgeon  should  bend  the  forearm  to  a  right  angle  with  the  arm, 
and  planting  one  heel  in  the  axilla,  with  one  hand  he  should  seize 
upon  the  loops  at  the  elbow,  and  with  the  other  steady  the  hand 
and  forearm  of  the  patient,  while  he  proceeds  to  make  firm  traction 
for  a  few  seconds  in  the  line  of  the  body,  or  only  a  little  out  from  this 

'  Boston  Med.  and  Surg.  Journ.,  vol.  xxxv.  p.  454. 


552  DISLOCATIONS    OF    THE    SHOULDER. 

line.  Failing  in  this,  he  may  direct  the  assistant  to  seize  upon  the 
scapula,  and  make  counter-extension ;  still  not  succeeding,  he  may 
change  his  foot  from  the  axilla  to  the  acromion  process  and  pull 
directly  outwards  at  a  right  angle  with  the  body,  or  he  may  swing 
himself  gradually  around  until  he  comes  to  be  above  the  head  of  the 
patient,  and  the  foot  presses  firmly  upon  the  top  of  the  scapula ;  now 
descending  again  in  the  same  direction,  he  will  very  probably  find  the 
limb  reduced,  or  capable  of  being  reduced  easily,  by  operating  upon  it 
as  a  lever  by  laying  it  across  the  body  while  at  the  same  moment  it 
is  rotated  slightly  outwards. 

If  still  the  reduction  is  not  accomplished,  the  pulleys  must  at  once 
be  put  in  requisition.  The  sheet  passed  around  the  chest  and  fastened 
to  a  staple,  is  only  a  means  of  supporting  the  body  and  rendering  it 
more  steady ;  as  a  means  of  counter-extension  its  value  is  inconsidera- 
ble. To  make  fast  the  scapula  we  must  still  rely  mainly  upon  the 
naked  hands  of  strong  men  or  upon  a  strap  drawn  firmly  across  the 
process  and  held  in  place  by  an  assistant. 

It  must  be  constantly  borne  in  mind  that  we  intend  to  conquer  the 
muscles  by  fatiguing  them,  and  that  this  cannot  be  done  by  a  force 
suddenly  applied,  however  great  it  may  be,  but  only  by  gentle,  steady, 
and  long-continued  extension.  The  muscles  when  attacked  openly 
and  vigorously,  resist,  and  will  suffer  laceration  rather  than  yield, 
while  on  the  other  hand,  an  insidious  but  persevering  approach  seldom 
fails  to  end  in  their  defeat.  The  forearm  is  again  flexed,  and  the  arm 
carried  out  to  a  right  angle  with  the  body,  the  pulleys  secured  to  the 
loops,  and  the  assistant  takes  hold  upon  the  process,  while  the  surgeon 
draws  gently  upon  the  rope  attached  to  the  pulleys ;  as  soon  as  every- 
thing is  moderately  tense,  he  is  to  desist  for  a  few  moments.  Again 
the  rope  is  drawn  upon  gently,  and  again  the  progress  of  the  extension 
is  suspended.  In  this  way  the  operator  is  to  proceed  during  half  an 
hour,  or  two  hours,  as  the  nature  of  the  case  may  demand ;  occasion- 
ally rotating  the  humerus,  and  occasionally  lifting  its  head  toward 
the  socket.  Meanwhile,  it  is  understood  that  the  principal  counter- 
extension  is  made  by  the  assistants,  who  must  relieve  each  other  at 
the  acromion  process.  The  sheet  in  the  axilla,  or  rather  against  the 
side  of  the  chest,  has  some  value  in  this  respect  when  the  arm  is  at  a 
right  angle  with  the  body,  but  in  itself  it  cannot  control  the  scapula, 
only  as  it  holds  the  body  to  which  the  scapula  is  attached.  Much, 
therefore,  as  we  may  regret  the  inconvenience  of  making  counter- 
extension  by  hands  alone,  experience  and  anatomy  alike  must  teach 
that  here  it  is  the  only  mode.  If  these  dislocations  are  reduced  often 
by  other  methods,  as  no  doubt  they  are,  then  it  is  only  an  evidence 
that  in  these  examples  little  or  no  counter-extension  was  necessary. 

Sometimes  the  dislocation  is  not  reduced  when  the  extension  is 
given  up,  but  if  then  a  resort  is  promptly  made  to  some  one  of  the 
simple  methods  already  described,  while  the  muscles  are  still  exhausted, 
it  very  often  happens  that  the  reduction  is  easily  accomplished. 

It  will  be  prudent  in  all  cases  in  order  to  prevent  a  reluxation, 
whether  the  dislocation  is  recent  or  ancient,  as  soon  as  its  reduction  is 


DISLOCATION    OF    THE    HUMERUS    DOWNWARDS.  553 

effected,  to  place  the  arm  in  a  sling  and  secure  the  elbow  to  the  side 
by  a  few  turns  of  a  roller.  I  do  not  think  the  axillary  pad  necessary, 
and  I  am  afraid  it  has  sometimes  done  as  much  mischief  as  the  dis- 
location itself. 

The  following  examples  will  illustrate  the  variety  of  expedients  to 
which  we  are  obliged  sometimes  to  resort  before  our  efforts  prove 
successful : — 

Thomas  Leeding,  of  Niagara  Co.,  IST.  Y.,  set.  52,  a  laborer  and  a 
muscular  man,  dislocated  his  right  arm  into  the  axilla  by  jumping 
from  the  cars  when  they  v\ere  in  full  motion.  The  blow  was  received 
upon  the  shoulder.  An  intelligent  country  surgeon,  assisted  by 
several  other  persons,  attempted  reduction  within  an  hour  after  the 
accident,  but  failed,  and  as  the  patient  had  some  distance  to  travel,  he 
was  not  brought  under  my  notice  until  eighteen  hours  had  elapsed. 
We  first  administered  chloroform,  and  then  while  an  assistant  held 
firmly  upon  the  acromion  process,  I  pulled  in  the  line  of  the  body, 
then  outwards,  and  finally  upwards,  but  to  no  purpose.  Having  then 
applied  Jar  vis's  "adjuster,"  and  after  the  arm  had  been  kept  extended 
at  a  right  angle  with  the  body  fifteen  minutes,  we  removed  the 
apparatus  and  found  the  bone  in  its  place. 

John  Harrington,  of  this  city,  set.  50,  a  very  large  and  powerful 
man,  fell  while  intoxicated,  and  dislocated  his  left  humerus  into  the 
axilla.  No  surgeon  was  called  until  the  tenth  day,  when  he  first  con- 
sulted Dr.  Dudley,  who  at  once  brought  him  to  me.  Without  delay 
we  applied  the  pulleys,  and  placing  the  arm  at  a  right  angle  with  the 
body  we  made  extension  fifteen  minutes;  occasionally  also  rotating 
the  arm.  We  then  removed  the  pulleys,  and  while  an  assistant  held 
upon  the  acromion  process,  with  my  heel  in  the  axilla  I  made  exten- 
sion in  the  line  of  the  axis  of  the  body,  then  outwards,  and  finally 
upwards  with  my  foot  upon  the  top  of  the  scapula,  I  next  seated  my 
patient  in  a  chair,  and  drew  his  arm  and  axilla  forcibly  over  my  knee. 
The  bone  was  not  yet  reduced ;  I  therefore  bled  him  twenty-four  ounces, 
or  until  partial  syncope  was  induced,  and  proceeded  to  repeat  most  of 
these  processes,  but  with  no  better  result.  At  this  moment  I  deter- 
mined to  use  sulphuric  ether,  which  had  just  been  introduced  as  an 
anassthetic,  and  while  he  was  completely  under  its  influence  the  pul- 
leys were  again  applied  and  the  extension  continued  for  some  time,  and 
until  the  rope  broke.  He  was  then  again  placed  in  a  chair,  and  the 
axilla  brought  over  my  knee,  when  in  a  moment  the  reduction  was 
accomplished. 

John  Bowles,  of  Buffalo,  aged  45  years,  an  Irish  laborer,  tolera- 
bly muscular,  but  spare.  Bowles  fell  down  a  flight  of  stairs,  and  dis- 
located his  left  humerus  into  the  axilla.  The  shoulder  became  much 
swollen,  and  was  very  painful,  but  he  did  not  suspect  a  dislocatiou, 
and  did  not  consult  a  surgeon.  Eight  weeks  after  the  accident  he  ap- 
plied to  me.  There  were  present  the  usual  signs  of  this  dislocation, 
but  the  arm  was  by  careful  measurement  one  inch  and  a  half  longer 
than  the  other. 

The  reduction  was  accomplished  on  the  same  day,  in  presence  of 
Drs.  Lee,  Webster,  Coventry,  Ford,  and  Jewett.     The  time  occupied 


554  DISLOCATIONS    OF    THE    SHOULDER. 

in  the  reduction  was  about  two  hours.  An  attempt  was  first  made 
with  the  heel  in  the  axilla  and  with  violent  rotation  and  extension. 
The  same  plan  was  repeated  with  the  aid  of  ether,  which  was  adminis- 
tered freely.  Jar  vis's  adjuster  was  now  applied,  with  no  result,  except 
that  either  in  consequence  of  the  force  employed  by  the  adjuster,  or 
in  consequence  of  the  free  use  of  ether,  or  of  both,  he  became  convulsed 
violently,  which  was  accompanied  by  frothing  at  the  mouth,  and  other 
grave  symptoms.  The  adjuster  was  removed,  and  the  exhibition  of 
ether  discontinued.  As  soon  as  the  convulsions  ceased,  and  before 
consciousness  had  returned,  extension,  rotation,  &c.,  were  again  made 
by  hands.  Finally,  after  all  extension  was  relinquished,  placing  my 
knee  in  the  axilla  I  reduced  the  bone  by  a  very  slight  rotary  action 
upon  the  arm.  The  bone  was  at  once  plainly  in  its  socket,  but  the 
unusual  length  of  the  limb  continued,  being  one  inch  and  a  half 
longer,  though  it  could  be  shortened  to  the  same  length  as  the  other 
by  lifting  the  elbow.  A  pad  was  placed  in  the  axilla,  and  the  arm 
secured  with  a  sling  and  roller.  The  next  day  the  arm  remained  in 
place,  but  it  was  now  only  one  inch  longer  than  the  other.  At  the 
end  of  a  fortnight  it  was  only  three-quarters  of  an  inch  longer,  and 
could  be  reduced  to  the  same  length  by  lifting;  the  pain  and  swelling 
about  the  shoulder,  which  never  were  great,  were  subsiding,  and  the 
patient  was  dismissed. 

However  skilfully  our  efforts  may  be  directed,  they  will  be  found 
occasionally  to  fail ;  either  owing  to  adhesions  which  have  taken  place, 
between  the  head  of  the  bone,  or  rather  its  capsule,  and  the  adjacent 
tendons,  muscles,  etc.,  to  some  extraordinary  position  of  the  head 
and  neck  of  the  bone  in  its  relation  to  ligamentous  or  tendinous  struc- 
tures, to  a  filling  up  of  the  glenoid  fossa,  or  to  some  other  cause  not 
fully  explained.  Such  failures  have  happened  not  only  in  the  hands  of 
ignorant  and  unskilful  surgeons  destitute  of  appliances,  but  also  in  the 
hands  of  those  who  are  the  most  expert,  and  who  are  the  most  com- 
pletely provided  with  all  the  necessary  apparatus.  Indeed,  if  the  truth 
were  known,  it  would  probably  be  found  that  the  number  of  failures 
has  been  greater  than  the  successes.  The  records  of  surgery,  how- 
ever, furnish  a  great  many  examples  of  ancient  dislocations  of  the 
humerus  reduced  after  periods  ranging  from  one  month  to  six,  or  even 
longer.  Dieff'enbach  has  been  able  to  accomplish  the  reduction  of  a 
forward  dislocation  after  two  years,  but  not  until  he  had  cut  the  ten- 
dons of  the  pectoralis  major,  latissimus  dorsi,  teres  major,  and  teres 
minor,  and  had  divided  the  ligaments  surrounding  the  new  joint.^ 

It  would  be  unjust  to  the  young  surgeon  not  to  call  especial  atten- 
tion to  the  numerous  examples  of  serious  and  even  fatal  accidents 
which  have  followed  upon  the  attempts  to  reduce  ancient  luxations  at 
this  joint.  My  friend,  George  C.  Blackman,  of  Cincinnati,  a  distin- 
guished surgeon,  having  recently  met  with  one  of  these  unfortunate 
accidents  in  his  own  practice,  has  had  the  candor  to  make  a  public 
statement  of  the  case  and  of  the  circumstances  which  attended  it.     In 

'  DiefFenbach,  Bost.  Med.  and  Surg.  Journ.,  vol.  xxii.  p.  382,  from  Medicin.  Zeitung. 


DISLOCATION    OF    THE    HUMERUS    DOWNWARDS.  555 

a  letter  to  the  editor  of  ttie  Western  Lancet^  published  in  the  November 
number  for  1856,  he  writes  as  follows  : — 

"  About  the  10th  ult.,  aided  by  yourself,  I  succeeded  in  reducing  by 
manipulation,  without  the  pulleys,  a  dislocation  into  the  axilla,  of  eighty 
days'  standing.  The  reduction  was  accomplished  in  a  very  few  minutes, 
under  the  influence  of  chloroform  and  ether,  and  the  next  morning  the 
patient  left  for  the  country,  in  a  comfortable  condition.  Since  that  I 
have  received  no  tidings  from  him.  Encouraged  by  the  result  in  this 
case,  another  patient,  himself  a  physician,  a  tall,  athletic  man,  and  about 
fifty  years  of  age,  decided  to  submit  to  the  same  manipulation,  although 
his  arm  had  been  dislocated  for  about  sixteen  weeks.  The  dislocation 
was  downwards  and  inwards,  and  about  the  tenth  week  an  unsuccessful 
attempt,  by  another  surgeon,  had  been  made  with  the  pulleys,  to  which 
the  force  of  six  men  was  applied  for  two  and  a  half  hours.  The  patient 
being  under  the  influence  of  chloroform  and  ether,  aided  by  yourself, 
Drs.  Fries,  Gary,  Graham,  and  KaufJman,  I  commenced  my  manipula- 
tions, adducting,  rotating,  abducting,  and  elevating  the  arm.  These 
efforts  had  been  made  for  about  ten  minutes,  and  the  least  possible 
violence  employed,  when  a  tumefaction  appeared  in  the  pectoral  region, 
which  in  a  few  minutes  attained  considerable  size.  Supposing  that 
the  axillary  artery  was  ruptured,  as  no  pulse  could  be  felt  at  the  wrist, 
a  ligature  was  immediately  applied  to  the  vessel  at  the  upper  part  of 
its  course.  The  operation  was  performed  about  10  o'clock  A.  M.,  and 
compression  of  the  pectoral  region  made  by  means  of  a  sponge  and 
broad  roller.  On  removing  this  the  next  morning,  the  tumefaction  had 
nearly  disappeared.  The  patient  continued  comfortable,  and  about 
nine  days  after  the  application  of  the  ligature,  I  was  compelled  to  leave 
the  city  on  a  professional  visit  to  Indiana.  I  left  on  Friday  after- 
noon and  returned  on  Monday  morning,  at  which  time  I  learned  that 
my  patient  had  died  on  Sunday  morning,  from  hemorrhage  at  the  seat 
of  ligature.  Two  physicians,  his  most  intimate  friends,  lodged  in  the 
same  house  with  him,  but  before  they  reached  his  bedside  the  quantity 
of  blood  lost  was  so  great  that  he  sank  exhausted  in  about  two  hours 
from  the  first  and  only  attack  of  hemorrhage.  Previous  to  my  depar- 
ture for  Indiana,  I  had  suggested  to  the  physicians  in  charge,  the  im- 
portance of  having  compressed  sponge  at  hand,  to  be  used  in  any 
emergency  of  the  kind,  but  this  was  not  used  by  the  attendant ;  instead 
of  applying  pressure  instantaneously,  he  went  in  search  of  the  physi- 
cians, who,  at  that  early  hour  in  the  morning,  were  in  bed.  The  time 
thus  lost  unquestionably  led  to  the  fatal  catastrophe. 

"  I  might  refer  you  to  numerous  instances  of  success  in  the  reduction 
of  old  dislocations — from  two  to  six  months'  standing — which  have 
occurred  since  the  days  of  Wiseman,  but  I  propose  to  notice  only  the 
accidents  by  which  some  of  these  attempts  have  occasionally  been 
followed.  One  of  the  earliest  recorded,  so  far  as  we  have  been  able 
to  learn,  is  the  case  reported  by  Desault.^ 

"  During  the  effort  of  this  surgeon  to  reduce  an  old  dislocation,  sud- 
denly a  considerable  Humeur  aerienne^  appeared  below  the  clavicle, 

•  Desault,  Journ.  de  Cliir.,  t.  iv.  p.  301. 


556  DISLOCATIONS    OF    THE    SHOULDER. 

which  Desault  attributed  to  the  '  degagement  de  Vair  amasse  entre  les 
cellules  romjmes  du  tissu  cellulaire  /'  In  a  few  days  this  tumor  entirely 
subsided  under  the  influence  of  ^astringents  et  une compression  methodiquej 
Whether  it  was  the  result  of  a  disengagement  of  air  from  the  lace- 
rated cells  of  the  cellular  membrane,  as  supposed  by  Desault,  or  of  a 
rupture  of  bloodvessels,  we  leave  the  reader  to  determine. 

"  It  is  somewhat  singular  that  Desault  should  have  met  with  two 
cases  of  this  extraordinary  phenomenon.  Pelletan's  explanation,  in 
our  opinion,  throws  some  light  on  this  subject.  In  an  attempt  to 
reduce  a  luxation  of  four  months'  standing,  the  same  kind  of  '  tumeur 
aerienne'  appeared.  It  was  opened,  and  the  hemorrhage  from  the  torn 
artery  was  fatal,^ 

"  Malgaigne  states  that  he  is  acquainted  but  with  a  single  instance 
of  an  '  eraphysdme  veritable'  following  a  reduction,  and  that  is  the 
one  reported  by  Flaubert,  in  his  Mem.  sur  ijlusieurs  cas  de  luxations 
dans  lesquels  les  efforts  pour  la  reduction  out  etc  suivis  d^accidents  graves, 
which  appeared  in  the  Repertoire  d'Anat.  et  de  Phys.,  1827.  The  patient, 
a  female,  ^t.  70,  screamed  violently  during  the  operation,  and  Mal- 
gaigne is  disposed  to  believe  that  the  emphysema  was  independent  of 
the  luxation,  or  the  reduction, 

"Malgaigne,  himself,  attempted  reduction  in  a  case  of  sixty-eight 
days'  standing,  but  was  forced  to  discontinue  his  efforts  in  consequence 
of  the  sudden  appearance  of  a  tumefaction  in  the  axilla,  and  on  the 
shojilder.  Ice  was  applied,  and  in  the  course  of  a  few  hours  the 
swelling  was  arrested,  and  by  the  twenty-second  day,  the  blood  which 
he  thinks  came  from  ruptured  muscular  branches,  was  completely 
absorbed.^ 

"A  case  occurred  to  Flaubert,  in  which,  besides  the  tumefaction, 
the  pulse  could  not  be  felt  at  the  wrist.  The  hand  was  cold,  insensible, 
and  immovable.  The  next  day,  however,  the  pulse  returned  to  the 
wrist,  and  in  the  course  of  twenty-six  days  the  effused  blood  was  ab- 
sorbed.  Froriep  lost  a  patient  from  a  rupture  of  the  axillary  vein, 
which  proved  fatal  in  an  hour  and  a  half  after  the  operation.  The 
reader  may  find  in  the  comprehensive  treatise  of  Malgaigne,  details 
of  cases  in  which  the  axillary  artery  was  ruptured.  We  pass  over 
those  observed  by  Verduc,  Petit,  Platner,  Delpech,  and  that  referred 
to  by  Sir  Charles  Bell,  in  his  Operative  Surgery.  The  late  Dr.  John 
C.  Warren  tied  the  subclavian  to  arrest  the  progress  of  an  enormous 
aneurismal  tumor  in  the  axilla,  the  result  of  the  reduction  of  a  recent 
dislocation,  and  of  supposed  pressure  of  the  operator's  boot.  In  this 
instance  the  coats  of  the  artery  were  so  contused  that  sloughing  took 
place  during  a  fit  of  coughing,  five  days  after  the  accident.^  In  1824, 
M.  Leudet  lost  a  patient  at  the  hospital  at  Eouen.  The  dislocation 
was  of  only  eleven  days'  standing,  and  was  complicated  with  a  frac- 
ture of  the  margin  of  the  glenoid  cavity,  as  in  the  two  fatal  cases 
which  occurred  in  the  practice  of  Prof,  Gibson,  of  Philadelphia.  The 
latter  cases  are  too  familiar  to  every  surgical  student  to  require  par- 

'  Pelletan,  Chir.  Clin.,  t.  ii.  p.  951.  "  Malgaigne,  op.  cit.,  p.  150. 

^  Warren,  Amer.  Journ.  Med.  Sci.,  vol.  xi.,  N.  S.,  1846. 


DISLOCATION    OF    THE    HUMERUS    DOWNWARDS.  557 

ticular  mention  in  this  place.  Prof.  Gibson,  in  connection  witli  tlie 
report  of  the  above  cases,  gives  briefly  the  details  of  a  fatal  operation 
by  David,  of  Eouen.  The  luxation  had  existed  several  months,  and 
great  force  was  employed  in  the  redaction.  This  resulted  in  an  inflam- 
mation, mortification,  and  death.  Some  years  since,  Lisfranc  attempted 
the  reduction  in  a  case  of  four  months'  standing.  He  succeeded ;  but 
on  visiting  the  patient  an  hour  afterwards  he  was  found  dead.  His 
death  was  attributed  to  cerebral  congestion,  as  the  autopsy  showed  the 
axillary  artery,  veins,  and  nerves  uninjured.'  In  the  same  volume, 
MM.  Lenoir  and  Larrey  refer  to  cases  in  which  they  had  met  with 
lesion  of  the  brachial  plexus,  giving  rise  to  paralysis,  and  yet  these 
were  recent  cases,  and  the  redaction  was  most  readily  accomplished. 
But  I  will  not  multiply  cases  of  this  kind ;  those  already  related  will 
suffice,  in  the  minds  of  many,  to  answer  the  question — At  what  period 
of  time  after  a  dislocation  of  the  shoulder,  is  an  attempt  at  reduction 
justifiable?  When  Prof.  Gibson  lost  his  first  patient,  he  wrote  that 
'should  a  case,  similar  in  external  appearance  to  that  of  James  Scofield 
again  occur,  I  shall  feel  justified  in  adopting  a  similar  course.'^  When 
he  had  lost  his  second  patient  (John  Langton),  he  expressed  his  views 
as  follows:  'The  conclusions  which  I  am.  now  prepared  to  draw  are 
directly  the  reverse  of  what  I  have  stated  in  some  of  the  foregoing 
pages  ;  I  am  now  disposed  to  condemn,  in  the  most  unqualified  terms, 
all  attempts  at  the  restoration  of  ancient  luxations  of  the  humerus 
and  other  bones — except  in  cases  where  the  patient  is  remarkably  thin 
and  debilitated,  and  where  there  has  been  little  or  no  inflammation  at 
the  time  or  subsequent  to  the  displacement.'  At  a  meeting  of  the 
Societe  de  Chirurgie  of  Paris,  July  3,  1850,  M.  Maisonneuve  reported 
a  case  in  which,  after  M.  Velpeau  had  failed,  he  succeeded  in  reducing 
a  luxation  of  the  shoulder  of  twelve  weeks'  standing,  and  elated  with 
this  triumph  over  the  veteran  of  La  Charite,  he  asserts  there  are  but 
few  cases  in  which,  with  the  aid  of  chloroform,  we  may  not  succeed. 
^Quelles  resistances  y  a-t-il  a  vaincre  ici,  en  effetT  he  asks.  '//  n^y  a 
presque  pas  d'engrenage ;  les  muscles  sont  neutralises  par  le  chloroforme ; 
il  ne  reste  done  que  des  adherences  fihreuses :  Von  pourra  'presque  toujours 
les  surmonter^ou  les  rompre'^  But  these  fibrous  adhesions  are  not  the  only 
obstacles  to  overcome:  where  the  tissues  surrounding  the  head  have 
become  consolidated  by  inflammation,  the  axillary  vessels  and  nerves 
must  be  in  danger  of  laceration.  Perhaps,  however,  as  M.  Maisonneuve 
suggests,  this  accident  may  be  avoided  by  '  extensions  preparatoires^  as 
in  the  attempts  to  restore  contracted  limbs  to  the  natural  shape." 

Korris  has  reported  three  cases  of  ancient  dislocation  into  the  axilla, 
treated  at  the  Pennsylvania  Hospital;  one,  of  four  weeks'  standing, 
was  reduced  in  thirty  seconds  by  the  aid  of  the  pulleys ;  the  second, 
which  had  existed  seven  weeks,  was  reduced  by  the  same  means  in 
about  one  hour;  and  the  third,  dislocated  ten  weeks,  was  left  unre- 
duced after  extension  and  counter-extension  had  been  made  for  an 
hour.     In  the  second  case,  however,  suppuration  occurred  in  or  about 

>  Lisfranc,  Bui.  de  la  Soc.  Chir.,  t.  i.  p.  718. 

2  Gibson,  Elements  of  Surg.,  vol.  i.  p.  824,  4th  ed. 

2  Maisonneuve,  Bui.  de  la  Soc.  Chir.,  t.  i.  p.  716. 


558  DISLOCATIONS    OF    THE    SHOULDER, 

the  joint,  and,  on  the  tenth  day,  the  abscess  was  opened,  giving  exit 
to  a  large  amount  of  pus.  He  left  the  hospital  with  the  parts  about 
the  shoulder  still  much  hardened  and  stiff.^ 


Dislocation,  with  Fracture  of  the  Humerus  near  its  Upper  End. 

We  have  thus  far  omitted  to  speak  of  the  treatment  of  dislocations 
of  the  humerus  accompanied  with  fracture  near  its  upper  end.  The 
elder  writers,  almost  without  an  exception,  agreed  in  declaring  the 
reduction  of  these  dislocations  impossible,  until  the  fracture  had  united. 
And,  so  late  as  the  year  1828,  we  have  the  report  of  a  case  treated  in 
this  manner  by  a  surgeon  in  Massachusetts.  Dr.  Warren,  of  Boston, 
himself  reduced  the  dislocation  at  the  end  of  four  weeks,  when  the 
fracture  was  found  to  have  united.^ 

But,  whatever  difficulty  surgeons  may  have  experienced  before  the 
introduction  of  anaesthetics,  it  is  quite  certain  that  at  the  present  day 
such  delay  is  no  longer  necessary,  at  least  in  a  great  majority  of  cases. 
In  order  to  the  reduction,  even  extension  and  counter-extension  are 
rendered  unnecessary,  provided  the  muscular  system  is  thoroughly 
relaxed,  for,  by  simply  pressing  firmly  the  head  of  the  bone  toward 
the  socket,  the  reduction  has  often  been  speedily  accomplished. 

Eichet  reports  an  example  of  this  kind  in  a  man  sixty-eight  years 
of  age,  in  whom  the  dislocation  was  complicated  with  a  fracture  of  the 
neck  of  the  humerus.  The  attempt  was  not  made  until  the  fourth 
day,  when  it  proved  successful  without  extension.  The  fracture  was 
afterwards  adjusted  and  consolidated  so  that  he  recovered  the  complete 
use  of  his  arra.^ 

At  a  meeting  of  the  New  York  Academy  of  Medicine  in  May,  1855, 
Dr.  Watson  reported  a  case  of  fracture  of  the  humerus  near  its  head, 
complicated  with  a  dislocation  into  the  axilla.  The  patient  was  a 
robust  man,  past  the  middle  age,  and  had  received  the  injury  by  a 
blow  on  the  shoulder  from  a  steam  engine.  He  was  very  much  pros- 
trated at  the  time  of  being  admitted  into  the  hospital,  and  the  exami- 
nation was  not  made  until  the  following  morning.  The  arm  was  then 
found  lying  close  to  the  side,  but  in  other  respects  it  presented  the 
usual  signs  of  a  dislocation.  Ether  was  immediately  administered; 
and  while  extension  and  counter-extension  were  applied,  and  a  sweeping 
motion  given  to  the  arm,  drawing  it  from  the  body,  firm  pressure 
with  the  fingers  was  made  in  the  axilla,  forcing  the  head  toward  the 
socket,  and  the  bone  slipped  into  its  position.^ 

In  the  Transactioyis  of  the  American  Medical  Association^  I  have  re- 
ported a  case  of  supposed  dislocation  accompanied  with  a  fracture, 
which  I  succeeded  in  reducing  on  the  eighth  day.^ 

Many  other  examples  have  been  recorded  by  other  surgeons  in 

'  Norris,  Amer.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  24. 

^  Boston  Med.  and  Surg.  Journ.,  No.  i.,  1828  ;  also,  Amer.  Journ.  Med.  Sci.,  vol.  ii. 
p.  233. 

^  Richet,  Amer.  Journ.  Med.  Sci.,  vol.  xii.,  new  ser.,  p.  293,  from  Bulletin  de  Therap. 
■*  Watson,  Amer.  Journ.  Med.  Sci.,  vol.  xvi.,  new  ser.,  p.  383. 
^  Op.  cit.j  vol.  ix.  p.  93. 


DISLOCATION    OF    THE    HUMERUS    FORWARDS.  559 

which  the  reduction  has  been  accomplished  immediately,  and  without 
much  difficulty,  by  simple  pressure  upon  the  head  of  the  bone,  while 
the  patient  was  under  the  influence  of  an  anaesthetic,  and  without  the 
aid  of  extension ;  indeed,  it  is  quite  doubtful  whether  extension  in 
these  cases  is  of  any  service.  If,  however,  the  surgeon  were  to  fail 
by  pressure  alone,  it  would  be  proper  to  employ  extension  and  mani- 
pulation ;^  in  the  event  of  a  failure  by  these  means,  the  case  ought 
to  be  treated  as  a  fracture,  and  the  earliest  period  after  the  union  of 
the  fragments  should  be  seized  upon  to  accomplish  the  reduction  of 
the  dislocation.  The  frequent  success  of  the  older  surgeons  by  this 
method  is  sufficient  to  warrant  the  attempt. 

The  treatment  of  compound  dislocations  of  this  joint  will  be  con- 
sidered in  a  separate  chapter  devoted  to  the  general  consideration  of 
compound  dislocations  of  all  the  joints  connected  with  the  long  bones. 


§  2.   Dislocation  op  the  Humerus  Forwards.     (Subcoracoid  and  Sub- 
clavicular.) 

Causes.  —  The  causes  of  this  dislocation  are  the  same  with  those 
which  produce  dislocation  downwards  into  the  axilla,  except  that  it  is 
more  likely  to  occur  in  a  fall  upon  the  elbow  or  upon  the  hand  when 
the  line  of  the  axis  of  the  arm  and  forearm  is  thrown  behind  the 
body.  If  it  is  the  result  of  a  direct  blow,  the  impulse  has  usually  been 
received  rather  upon  the  back  than  upon  the  outer  side  of  the  head  of 
the  humerus;  or  the  upper  end  of  the  bone  having  been  originally 
thrown  directly  downwards  upon  the  inferior  edge  of  the  scapula,  may 
have  been  made  to  assume  the  position  forwards  beneath  the  pectoral 
muscle,  in  consequence  of  the  peculiar  action  of  the  muscles,  or  of  the 
position  of  the  arm  in  an  attempt  to  rise.  By  this  latter  mode  of  ex- 
planation the  dislocation  forwards  is  consecutive  only  upon  a  disloca- 
tion downwards. 

In  several  instances  which  have  come  under  my  notice  the  dislo- 
cation has  been  due  to  muscular  action  alone.  In  one  example  the 
dislocation  occurred  frequently  in  consequence  of  epileptic  convulsions. 
This  was  in  the  person  of  a  lad,  set.  18,  of  a  slender  frame  and  feeble 
muscles.  When  the  dislocation  had  taken  place,  he  was  frequently 
able  to  reduce  it  himself;  sometimes  he  was  obliged  to  call  upon  a  sur- 
geon, and  at  other  times  he  left  it  out  a  day  or  two,  or  until  it  became 
reduced  spontaneously.  This  spontaneous  reduction  generally  took 
place  at  night,  during  sleep.  At  the  time  he  called  upon  me  the  bone 
had  been  out  two  days,  and  he  could  not  reduce  it.  I  administered 
chloroform,  and  then  made  repeated  and  prolonged  efforts  to  reduce 
it,  adopting  all  the  usual  modes  of  manipulation,  but  without  resort- 
ing to  mechanical  appliances.  The  father  now  refused  to  allow  me 
to  proceed,  and  he  was  taken  home  with  the  bone  unreduced.  The 
following  day  he  called  at  my  office,  to  say  that  during  the  night,  while 

'  Hartsliorne,  Case  reduced  by  Manipulation,  Amer.  Journ.  Med.  Sci.,  Jan.  1855, 
pp.  273-4,  from  Med.  Examiner. 


560 


DISLOCATIONS    OF    THE    SHOULDER. 


Fig.  229. 


asleep,  and,  he  thinks,  while  turning  over  in  bed,  the  bone  suddenly 
resumed  its  place. 

Pathology. — Omitting  for  the  present  to  speak  of  partial  luxations, 
the  existence  of  which,  as  a  form  of  traumatic  dislocation,  we  are  pre- 
pared to  question,  we  shall  proceed  at  once  to  describe  the  anatomical 
relations  and  the  various  lesions  which  generally  accompany  a  com- 
plete luxation  forwards. 

Of  these  we  shall  observe  two  principal  varieties,  differing  mainly 
in  the  degree  or  extent  of  the  displacement. 

Thus,  we  may  find  the  head  of  the  humerus  resting  beneath  the 
coracoid  process  (Fig.  229),  having  the  conjoined  tendon  of  the  short 
head  of  the  biceps  and  of  the  coraco-brachialis  lying 
upon  its  anterior  surface,  while  its  posterior  and 
outer  surface  rests  upon  the  venter  of  the  scapula 
in  front  of  the  glenoid  fossa ;  in  which  position  it 
has  usually  thrust  up,  to  a  greater  or  less  extent, 
the  belly  of  the  subscapular  muscle. 

Sir  Astley  Cooper,  Fergusson,  and  others,  when 
mentioning  this  form  of  dislocation,  call  it  a  "dis- 
location into  the  axilla ;"  by  Boyer  it  is  called  a 
"primary  luxation  forwards."  Dr.  Wood,  of  New 
York,  has  reported  an  example,  accompanied  with 
a  fracture  of  the  neck  of  the  humerus,  which  he  has 
named  "dislocation  under  the  subscapularis  mus- 
cle." The  drawing  which  accompanies  the  report, 
made  from  the  autopsy,  sufficiently  shows  that  it 
was  a  dislocation  of  the  same  character  which  we  are  now  describing.^ 
And  Dr.  Parker,  of  the  same  city,  has  called  attention  to  a  similar 
case,  an  account  of  which  was  first  given  in  Eeese's  edition  of  Cooper's 

Surgical  Dictionary.  The  head  of  the 
humerus  reposed  in  the  "subscapular 
fossa."*  By  Malgaigne,  Vidal  (de  Cas- 
sis), and  others,  this  is  called  a  subcora- 
coid  dislocation,  a  term  which,  as  being 
more  distinctive  and  appropriate  than 
either  of  the  others,  I  shall  choose  to 
adopt. 

In  the  second  variety  (Fig.  280), 
the  head,  having  escaped  from  under- 
neath the  coracoid  process,  is  made 
to  approach  nearer  to  the  sternum,  so 
as  to  apply  itself  more  or  less  closely 
to  the  inferior  edge  of  the  clavicle.  In 
which  case  the  head  and  neck  will  be 
placed  behind  both  the  pectoralis  major 
and  minor,  and  also  behind  the  short 
head  of  the  biceps  and  coraco-brachi- 


Subcoracoid  dislocation. 


Fig.  230. 


Subclavicular  dislocation. 


>  Wood,  New  York  Journ.  of  Med.,  May,  1850,  p.  282. 
2  Parker,  New  York  Jouru.  of  Med.,  March,  1852,  p.  187. 


DISLOCATIOiSr    OF    THE    HUMERUS    FORWARDS. 


561 


alis ;  or  between  these  several  muscles  on  the  one  hand,  and  the  ser- 
ratus  magnus,  covering  the  second  and  third  ribs,  on  the  other  hand. 

It  is  in  this  latter  position  that  the  head  of  the  humerus  is  usually 
found,  and  upon  the  appearances  which  accompany  this  more  advanced 
form  of  dislocation  writers  have  generally  based  their  descriptions, 
diagnosis,  treatment,  &;c.,  of  forward  luxations. 

In  either  form  of  the  accident,  the  deltoid,  with  the  supra-  and  infra- 
spinatus, is  greatly  stretched,  and  the  two  latter  sometimes  torn;  the 
subscapularis  is  displaced  upwards  and  backwards,  while  its  tendon  is 
in  some  instances  completely  wrenched  from  the  head  of  the  humerus. 
Mr.  Erichsen  has  seen  the  lesser  tubercle  itself  completely  broken  off 
in  two  examples  of  this  accident  which  he  has  been  permitted  to  exa- 
mine after  death. ■"  Occasionally  the  axillary  nerves  are  carried  for- 
wards with  the  head  of  the  bone ;  and  in  this  case  the  pain  produced 
by  their  being  thus  pressed  upon  is  even  greater  than  in  dislocations 
into  the  axilla. 

In  this  accident,  as  in  dislocation  downwards,  the  long  head  of  the 
biceps  is  sometimes  broken;  the  circumflex  nerve  may  be  contused  or 
ruptured,  and  the  capsule  is  generally  torn  very  extensively. 

Symptoms. — If  the  dislocation  is  subclavicular  (Fig.  230),  a  depression 
exists  under  the  outer  end  of  the  acromion  process,  extending  also  un- 

Fig.  231. 


Subcoracoid  luxation. 


derneath  its  posterior  margin;  the  elbow  hangs  away  from  the  body, 
and  a  little  backwards ;  the  axis  of  the  limb  is  much  changed,  being 


36 


Ericliaen,  Science  and  Art  of  Surgery,  2d  Amer.  ed.,  p.  250. 


562  DISLOCATIONS    OF    THE    SHOULDER. 

thrown  inwards  in  the  direction  of  the  middle  of  the  clavicle,  the 
whole  body  inclining  moderately  to  the  same  side ;  there  is  also  more 
or  less  inability  to  move  the  arm,  especially  in  a  direction  forwards  or 
outwards ;  a  fulness  is  seen  underneath  the  clavicle,  and  to  the  sternal 
side  of  the  coracoid  process,  occasioned  by  the  head  of  the  humerus ; 
the  head  moving  with  the  shaft.  To  these  we  may  add  the  common 
sign  of  all  dislocations  of  the  humerus,  mentioned  by  Dugas,  viz  :  the 
impossibility  of  placing  the  hand  upon  the  opposite  shoulder  while  at 
the  same  moment  the  elbow  is  made  .to  touch  the  front  of  the  chest. 

If  the  dislocation  is  forwards,  but  subcoracoid  (Fig.  281),  the  head 
of  the  bone  will  be  found  below  this  process  and  deep  in  the  anterior 
margin  of  the  axillary  fossa.  It  cannot,  therefore,  be  so  distinctly  felt; 
but  the  other  signs  are  the  same  as  in  the  dislocation  forwards  under 
the  clavicle. 

Prognosis. — "While  on  the  one  hand  experience  has  shown  that  the 
axillary  nerves  and  artery  are  less  liable  to  suffer  serious  and  permanent 
injury  than  in  dislocation  downwards,  and  that  the  capsule,  with  the 
tendinous,  and  muscular  tissues  about  the  joint,  are  no  more  liable  to 
laceration,  on  the  other  hand,  the  difficulty  of  reduction  has  been  often 
increased,  and  consequently  a  larger  number  of  examples,  in  propor- 
tion to  the  actual  number  which  occur,  have  been  left  unreduced. 

Dr.  Norris  relates  a  case  which  the  surgeon  who  was  first  called 
supposed  to  be  a  mere  contusion,  but  which,  on  being  admitted  to  the 
Pennsylvania  Hospital,  three  months  after  the  accident,  was  found  to 
be  a  dislocation  forwards  under  the  clavicle.  The  arm  was  almost 
useless.  Dr.  Norris  made  extension  and  counter-extension  with  pul- 
leys nearly  an  hour,  but  to  no  purpose ;  and  finally,  at  the  request  of 
the  patient,  the  attempt  was  given  over.^ 

Treatment. — The  same  rules  of  treatment  which  we  have  established 
in  relation  to  dislocations  into  the  axilla  will  be  found  to  be  applicable 
to  this  dislocation,  with  the  exception  that  the  extension  will  have  to 
be  made,  generally  at  first,  somewhat  in  a  line  backwards  from  the 
body,  and  that  our  efforts  will  frequently  have  to  be  continued  with 
more  perseverance,  although  with  less  fear  of  injury  in  consequence  of 
supposed  adhesions  between  the  artery  and  the  adjacent  tissues.  The 
extension  also  must  always  be  made  downwards  and  outwards,  if  the 
dislocation  is  subclavicular,  until  the  head  of  the  bone  has  escaped 
from  beneath  the  coracoid  process ;  we  may  then  pull  directly  out- 
wards or  even  upwards,  while  at  the  same  moment  pressure  is  made 
with  the  hand  upon  the  head  of  the  bone  in  the  direction  of  the  socket. 

If  the  dislocation  is  subcoracoid,  our  modes  of  procedure  need 
scarcely  vary  in  any  respect  from  those  which  we  have  recommended 
for  dislocations  into  the  axilla. 

The  plan  adopted  in  the  following  case  has  been  found  sufficient  in 
several  examples  of  subcoracoid  dislocation. 

Mr.  McA.,  of  Buffalo,  «t.  73,  moderately  muscular,  fell  through  a 
trap-door,  striking  upon  his  right  elbow  and  dislocating  the  humerus 
forv/ards.     Within  two  hours  after  the  accident  I  found  the  head  of 

'  Norris,  Amer.  Journ.  iSIed.  Sci.,  vol.  xxv.  p.  279. 


DISLOCATION    OF   THE    HUMERUS    FORWARDS.  563 

the  bone  resting  under  the  coracoid  process,  where  it  could  be  dis- 
tinctly felt  and  seen.  There  was  a  marked  depression  under  the 
acromion  process,  and  the  arm  was  carried  out  from  the  body  and 
slightly  back.  He  had  not  suffered,  much  pain.  The  patient  was 
seated  in  a  chair,  and  while  Dr.  Lemon,  who  was  at  that  time  my 
pupil,  supported  the  acromion  process,  I  pushed  the  head  of  the 
humerus  outwards  toward  the  socket,  with  ray  left  hand,  while  with 
my  right  I  pulled  gently  upon  the  arm  in  the  direction  of  the  axis  of 
the  body.  After  about  twenty  seconds  it  slid  suddenly  into  its  place 
with  an  audible  snap. 

Simple  manipulation  alone  will  also  be  found  sufficient  in  many 
cases  of  subclavicular  dislocation. 

A  German,  Simeon  Grennas,  set.  21,  fell  upon  an  icy  side-walk  and 
dislocated  his  right  humerus  under  the  clavicle.  We  found  him  about 
an  hour  after  the  accident  sitting  with  his  head  inclined  to  his  right 
side,  and  supporting  his  elbow  with  his  left  hand.  A  marked  depres- 
sion existed  under  the  outer  end  of  the  acromion  process,  and  instead 
of  the  usual  fulness  there  was  a  flatness  under  the  process  behind. 
The  elbow  was  carried  out  from  the  body  and  very  slightly  backwards. 
While  Dr.  Boardman  supported  the  acromion  process  I  lifted  the  elbow 
from  the  side,  carrying  it  first  upwards  and  backwards,  and  then  for- 
wards, making  thus  a  short  detour  with  the  arm,  and  when  the  ma- 
noeuvre was  nearly  completed  the  bone  slid  into  its  socket  with  a  slight 
snap.  No  extension  was  used,  and  no  more  force  was  employed  than 
was  sufficient  to  lift  and  rotate  the  arm.  He  was  not  at  the  time  of  the 
reduction  faint,  nor  were  his  muscles  relaxed  from  any  other  cause. 

More  than  once  I  have  accomplished  the  reduction  by  extension 
made  directly  upwards,  as  in  the  following  example. 

A  gentleman,  forty-five  years  of  age,  had  his  left  shoulder  dislocated 
forwards  under  the  clavicle  in  a  railroad  collision  on  the  8th  of  Octo- 
ber, 1858.  A  young  surgeon  had  been  making  extension  in  various 
ways  for  half  an  hour,  when,  by  placing  my  foot  upon  the  top  of  the 
scapula  and  drawing  the  arm  directly  upwards,  I  accomplished  the 
reduction  immediately  and  without  much  effort.  Six  months  after 
the  accident,  I  found  the  deltoid  muscle  considerably  wasted,  and  he 
was  still  unable  to  raise  his  arm  to  a  right  angle  with  the  body. 

I  have  in  this  way  also  reduced  a  dislocation  which  had  existed 
seventeen  days,  the  nature  of  the  accident  having  been  misunderstood 
by  the  attending  surgeon.  The  man  was  twenty-three  years  old,  and 
quite  muscular.  The  dislocation  had  been  produced  by  a  severe  blow 
received  directly  upon  the  shoulder,  and  the  arm  was  still  considerably 
swollen  and  very  tender.  The  reduction  was  accomplished  in  a  few 
seconds  while  the  patient  was  under  the  influence  of  chloroform,  but 
by  my  hands  alone,  aided  only  by  the  pressure  of  the  foot  upon  the 
top  of  the  scapula. 

In  December,  1857,  Dr.  White,  of  this  city,  and  myself  reduced  a 
subclavicular  dislocation  of  the  right  shoulder,  which  had  existed  sixty 
days,  in  a  man  sixty-eight  years  of  age.  The  surgeon  who  first  saw 
the  man  thought  it  was  only  a  sprain  or  a  severe  bruise.  When  he 
came  to  Buffalo,  the  whole  limb  was  enormously  swollen,  and  neither 


564  DISLOCATIONS    OF    THE    SHOULDEE. 

Dr.  Wbite  nor  myself  had  mucli  expectation  of  accomplishing  a  reduc- 
tion without  a  resort  to  pulleys  and  anaesthetics.  He  was,  however, 
placed  upon  the  floor,  and  after  extension  made  for  about  half  an 
hour,  during  which  time  we  had  pulled  the  arm  in  various  directions, 
upwards,  outwards,  and  downwards,  I  at  last  succeeded  while  my  heel 
was  placed  in  the  axilla,  and  while  the  limb  was  undergoing  a  slight 
rotation.     No  aneesthetic  was  employed. 

These  several  cases  are  mentioned  that  the  surgeon  may  understand 
how  impossible  it  is  always  to  establish  absolute  and  invariable  rules 
of  procedure  which  shall  be  applicable  to  every  accident  of  this  cha- 
racter. The  method  which  will  succeed  readily  in  one  case  may  fail 
completely  in  another,  although  belonging  to  the  same  class,  and  not 
apparently  differing  in  its  anatomical  relations.  Before  relinquishing 
the  attempt,  we  ought  to  have  put  in  requisition  all  the  expedients 
which  the  experience  of  other  surgeons  has  shown  to  be  worthy  of  a 
trial. 

§  3.  Dislocation  of  the  Humerus  Backwards.     (Subspinous.) 

This  form  of  dislocation  has  been  seldom  met  with.  Only  two 
cases,  according  to  Sir  Astley  Cooper,  occurred  in  Guy's  Hospital  in 
thirty-eight  years;  but  in  the  last  edition  of  Sir  Astley  Cooper's 
treatise  on  Fractures  and  Dislocations,  edited  by  Bransby  Cooper,  nine 
cases  are  mentioned.^  Sedillot,^  Malgaigne,  Desclaux,^  Van  Buren,* 
W.  I'arker,*  Lepelletier,^  Trowbridge,^  Physick,  and  Snyder,*  have  each 
seen  one  example.^ 

Causes. — One  of  the  patients  mentioned  in  Mr.  Cooper's  book  had 
his  shoulder  dislocated  backwards  in  an  epileptic  convulsion ;  one  had 
fallen  upon  his  shoulder;  another  met  with  the  accident  while  pushing 
a  person  violently  with  the  arm  elevated  ;  and  a  fourth,  seen  by  Mr. 
Coley,  "  was  pulled  down  by  a  calf  which  he  was  driving,  a  cord 
having  been  tied  to  one  of  the  calf's  legs,  and  being  held  fast  by  the 
man's  hand."  Of  the  manner  in  which  the  other  cases  were  produced 
no  precise  account  is  given.  Desclaux's  patient  fell  from  a  height 
with  his  arm  in  front  of  him.  In  the  case  seen  by  Dr.  Parker,  of 
New  York,  a  woman,  set.  60,  had  fallen  forwards  and  struck  upon  the 
outside  of  her  elbow,  arm,  and  shoulder.  No  attempt  was  made  to 
reduce  it  until  the  fourteenth  day,  she  not  having  for  some  time  called 
the  attention  of  any  surgeon  to  its  condition.  Trowbridge's  patient 
was  thrown  from  a  horse,  striking  on  the  palm  of  his  hand. 

Pathology. — Mr.  Cooper  has  given  us  a  careful  account  of  the  dis- 
section in  the  case  of  Mr.  Complin,  already  alluded  to,  whose  arm  had 
been  dislocated  by  muscular  spasm.     This  gentleman  was  fifty-two 

'  a.  Cooper,  op.  cit.,  p.  352,  etc. 

^  Sedillot,  Amer.  Journ.  of  Med.  Sci.,  vol.  xiii.  p.  551,  Feb.  1834. 
^  Desclaux,  New  York  Journ.  of  Med.,  Nov.  1851,  p.  109,  from  Revue  Medicale. 
*  Van  Buren,  ibid.,  Nov.  1851,  p.  110.  ^  Parker,  ibid.,  March,  1852,  p.  186. 

6  Lepelletier,  Amer.  Journ.  Med.  Sci.,  vol.  xvi.  p.  526,  from  Arch.  Gen.,  Nov.  1834. 
■^  Trowbridge,  Bost.  Med.  and  Surg.  Journ.,  vol.  xxvii.  p.  99.  ^  Gibson's  Surgery. 

°  Examples  have  also  been  seen  by  Dupuytren,  Arnolt,  Best,  Levacher,  Berard,  Fi- 
zeau,  "Velpeau,  Fergusson  and  Kirkbride.    New  York  Journ.  Med.,  March,  1852,  p.  193. 


DISLOCATION    OF    THE    HUMERUS   BACKWARDS. 


565 


years  of  age,  and  had  been  subject  to  epileptic  fits,  in  one  of  which 
the  shoulder  was  dislocated.  Many  attempts  were  made  to  reduce  it, 
but  although  it  seemed  to  be  easily  drawn  into  its  socket  by  extension 
merely,  yet,  as  soon  as  the  force  ceased,  the  head  of  the  bone  slipped 
again  upon  the  dorsum  scapulae,  and  in  this  situation  it  was  finally 
permitted  to  remain  until  his  death,  which  did  not  take  place  until 
five  years  after.  In  the  mean  time,  he  was  able  to  move  the  limb 
but  very  slightly,  so  that  his  arm  was  almost  useless. 

Mr.  Cooper,  to  whom  the  arm  was  sent  after  death,  found  the  head 
of  the  bone  resting  under  the  spine  of  the  scapula,  and  against  the 
posterior  edge  of  the  glenoid  fossa,  where  it  had  formed  a  slight 
depression,  and  the  head  itself  had  become  somewhat  changed  in  form 
by  absorption.  The  tendon  of  the  subscapularis  muscle  and  the 
internal  portion  of  the  capsular  ligament  were  torn  at  the  point  where 
the  muscle  was  inserted,  but  the  greater  portion  of  the  capsule  re- 
mained, having  been  pressed  back  by  the  head  of  the  bone.  The 
supra-spinatus  was  stretched,  while  the  infra-spinatus  and  teres  minor 
were  relaxed.  The  long  head  of  the  biceps  was  elongated  but  not 
ruptured.  Tlie  glenoid  fossa  was  rough  and  irregular  upon  its  surface, 
the  cartilage  being  absorbed. 

The  fact  that  the  bone  would  not  remain  in  place  when  reduced, 
was  explained  by  the  rupture  of  the  subscapularis,  and  the  consequent 
loss  of  antagonism  to  the  action  of  the 
infra  spinatus  and  teres  minor.' 

The  accompanying  drawing  is  a  copy 
of  that  furnished  by  Mr.  Cooper  to  illus- 
trate the  position  occupied  by  the  bone. 

I  ought  to  mention  that  this  case  has 
been  regarded  by  Yidal  (de  Cassis),  Mal- 
gaigne,  and  others,  as  only  subacromial, 
and  as  a  variety  of  the  dislocation  back- 
wards, differing  from  that  in  which  the 
head  of  the  bone  occupies  a  position 
underneath  the  spine.  But  as  I  can  see 
no  difference  except  in  the  degree  or 
extent  of  the  displacement,  I  prefer  not 
to  regard  the  distinction  made  by  these 
surgeons. 

SymxAoms. — The  signs  of  this  acci- 
dent are,  a  projection  under  the  spine 

of  the  scapula,  produced  by  the  head  of  the  bone,  the  head  being 
obedient  to  the  motions  of  the  arm;  a  corresponding  depression 
in  front  and  under  the  outer  extremity  of  the  acromion  process ;  a 
wide  space  between  the  head  of  the  bone  and  the  coracoid  process,  into 
which  the  fingers  may  be  pushed  deeply ;  the  axis  of  the  shaft  of  the 
humerus  directed  upwards  and  outwards  toward  a  point  posterior  to 
the  glenoid  fossa ;  the  arm  laid  against  the  side  of  the  body,  and  car- 
ried forwards  across  the  chest ;  the  humerus  rotated  inwards,  unless 


Subspinous  dislocation. 


Sir  A.  Cooper,  op.  cit.,  p.  354. 


566  DISLOCATIONS    OF    THE    SHOULDER. 

the  subscapularis  muscle  is  torn ;  immobility,  but  the  motions  of  the 
arm  are  not  generally  so  much  impaired  as  in  either  of  the  other  dis- 
locations; and  finally,  as  in  all  other  dislocations  of  the  humerus,  the 
hand  cannot  be  laid  upon  the  opposite  shoulder  while  the  elbow 
touches  the  side  or  front  of  the  chest.  In  Parker's  case  the  elbow 
was  thrown  outwards,  although  the  arm  was  carried  very  much  across 
the  chest.  Desclaux's  patient  held  his  hand  upon  his  head,  with  his 
arm  horizontally  across  his  body. 

Usually  the  diagnosis  will  be  easily  made,  but  Sir  Astley  relates 
one  case  in  which,  on  the  morning  following  the  accident,  a  surgeon 
was  unable  to  discover  the  dislocation,  and  on  the  seventeenth  day 
Bransby  Cooper  failed  to  make  the  diagnosis;  nor  indeed,  on  the 
twenty-third  day  did  Sir  Astley  himself  determine  that  it  was  a  dis- 
location, until  he  had  unexpectedly  reduced  it  while  manipulating 
upon  the  arm.  In  a  second  example.  Sir  Astley  at  first  believed  it  to 
be  a  fracture,  but  a  more  careful  examination  showed  it  to  be  a  dislo- 
cation backwards.  In  this  instance  the  limb  could  not  be  rotated  out- 
wards, as  the  subscapularis  was  not  torn,  and  continued  to  oft'er  resist- 
ance when  the  arm  was  moved  in  this  direction;  he  was  also  suffering 
much  more  pain  than  did  the  other  patients,  owing,  as  Sir  Astley 
thinks,  to  pressure  upon  the  articular  nerves.  In  the  case  of  Mr. 
Collinson,  also  mentioned  by  Mr.  Cooper,  a  surgeon  who  saw  the 
patient  immediately  after  the  accident,  failed  to  discover  the  true 
nature  of  the  injur}?";  and  Trowbridge's  patient  had  suffered  a  disloca- 
tion several  weeks  before  the  nature  of  the  accident  was  fully  deter- 
mined. 

Prognosis. — The  reduction  has  always  been  sooner  or  later  accom- 
plished, except  in  one  instance;  in  this  case  we  have  seen  that  the  arm 
never  recovered  any  considerable  degree  of  usefulness.  Mr.  Collinson's 
arm,  reduced  on  the  second  day,  was  restored  to  all  of  its  functions 
within  one  month.  Dr.  Parker's  patient  had  nearly  recovered  the 
complete  use  of  her  arm  at  the  end  of  four  weeks,  although  it  was  not 
reduced  until  it  had  been  out  fourteen  days.  Sedillot  succeeded  in 
reducing  the  dislocation  in  the  case  of  his  patient,  at  the  end  of  one 
year  and  fifteen  days.  Lepelletier  after  forty-five  days.  Trowbridge 
after  forty  days,  and  in  this  latter  case,  we  are  informed  that  the  arm 
was  restored  to  usefulness. 

Treatment. — In  the  first  case  mentioned  by  Sir  Astley  Cooper,  "the 
bandages  were  applied  in  the  same  manner  as  if  the  head  of  the  hume- 
rus had  been  in  the  axilla,  and  the  extension  was  made  in  the  same 
direction  as  in  that  accident"  (downwards  and  a  little  outwards).  In 
less  than  five  minutes  the  bone  slipped  into  its  socket  with  a  loud  snap. 
The  second  case  was  treated  successfully  in  the  same  way.  Mr.  Dunn 
also  having  failed  to  reduce  by  pulling  upwards,  finally  succeeded  by 
pulling  at  the  wrist  downwards  and  forwards,  while  an  assistant  pushed 
the  head  of  the  bone  toward  the  socket ;  the  heel  was  not  placed  in 
the  axilla,  which  Mr.  Bransby  Cooper  thinks  would  have  only  retarded 
the  reduction.  Mr.  Key  also  failed  to  accomplish  reduction  while  car- 
rying the  arm  upwards  and  backwards,  but  when  the  patient  had  be- 
come faint,  by  placing  the  heel  in  the  axilla  and  pulling  downwards  a 


PARTIAL    DISLOCATIONS    OF    THE    HUMERUS.  567 

minute  or  two,  the  bone  was  reduced.  Vidal  (de  Cassis)  recommends 
the  same  plan,  namely,  that  we  shall  pull  in  the  direction  in  which  we 
find  the  limb;  Trowbridge  employed  the  pulleys  successfully,  the  ex- 
tension being  made  downwards  and  forwards :  while  Dr.  Parker  suc- 
ceeded equally  well  with  his  patient,  by  "pulling  the  arm  outwards, 
downwards,  and  slightly  forwards."  Counter-extension  was  at  the  same 
time  made  by  a  sheet  in  the  axilla,  and  the  head  of  the  humerus  was 
pushed  toward  the  socket  by  the  hand.  In  Mr.  Collinson's  case,  the 
scapula  was  supported  by  a  towel,  while  "  gradual  extension  of  the 
limb  was  made  directly  outwards,  and  then  the  arm  being  moved  slowly 
forwards,  the  head  of  the  bone  was  distinctly  heard  to  snap  into  its 
socket."  The  time  occupied  was  not  more  than  two  or  three  minutes. 
Sir  Astley,  however,  seems  to  give  the  preference  to  the  method  which 
succeeded  so  happily  in  the  case  of  Mr.  G.,  while  he  was  still  manipu- 
lating with  a  view  to  determine  the  character  of  the  accident.  "  I  readily 
reduced  the  bone,"  he  remarks,  "by  raising  the  hand  and  arm,  and  by 
turning  the  hand  backwards  behind  the  head."  In  one  other  instance, 
having  failed  to  reduce  it  by  slight  extension  outwards,  he  raised  the 
arm  perpendicularly,  and  at  the  same  time  forced  it  backwards  behind 
the  patient's  head,  and  the  reduction  was  promptly  eft'ected. 

After  the  reduction,  a  compress  should  be  placed  against  the  head 
of  the  bone,  and  underneath  the  spine  of  the  scapula,  and  this  should 
be  secured  in  its  place  by  several  turns  of  a  roller.  The  forearm 
ought  also  to  be  placed  in  a  sling,  with  the  elbow  thrown  a  little  back 
of  the  centre  of  the  body,  so  as  to  direct  the  head  of  the  humerus 
forwards. 


§  4.  Partial  Dislocations  of  the  Humerus. 

Sir  Astley  Cooper  has  related  in  his  treatise  two  cases  of  supposed 
incomplete  luxation  of  the  head  of  the  humerus  forwards;  and  in  con- 
firmation of  his  views  he  has  added  an  account  of  the  appearances 
presented  on  dissection  in  the  body  of  a  subject  brought  into  the 
rooms  of  St.  Thomas's  Hospital.  Bransby  Cooper,  in  his  edition  of 
the  same  work,  furnishes  the  report  of  a  similar  case  which  came 
under  the  observation  of  Mr.  Douglas,  of  Glasgow.  Hargrave  and 
Dupuytren  have  each  reported  one  example  of  this  species  of  dislo- 
cation, in  which  its  existence  was  said  to  be  confirmed  by  dissection. 

Petit,  Duverney,  Chopart,  Sedillot,  Miller,  Gibson,  Malgaigne,  and 
many  others  have  admitted  its  possibility ;  Malgaigne,  however,  only 
admits  its  existence  when  the  capsule  remains  entire. 

Without  intending  to  examine  very  much  at  length  the  value  of 
these  opinions,  I  shall  content  myself  with  declaring  that  the  exist- 
ence of  this,  or  of  any  other  form  of  partial  luxation  of  the  shoulder- 
joint,  as  a  traumatic  accident,  has  not  up  to  this  moment  been  fairly 
established;  and  that  the  anatomical  structure  of  the  joint  renders  its 
occurrence  exceedingly  improbable,  if  not  absolutely  impossible. 

The  only  example  mentioned  by  Sir  Astley  Cooper,  in  which  a 
dissection  was  made,  showed  that  the  long  head  of  the  biceps  had 


568 


DISLOCATIONS    OF    THE    SHOULDER. 


been  ruptured,  and  that  the  capsule  was  torn,  while  the  head  of  the 
humerus  was  resting  under  the  coracoid  process.  We  shall  have  no 
difficulty,  therefore,  in  assigning  it  to  its  proper  place  as  a  complete, 
sub-coracoid  dislocation.  In  Mr,  Hargrave's  case,  also,  the  tendon  of 
the  biceps  was  torn  ;  while  Dupuytren  omits  to  mention  what  was  the 
actual  fact  in  relation  to  this  tendon  in  the  case  seen  by  him,  but  it  is 
distinctly  stated  that  the  head  of  the  bone  rested  upon  the  ribs.  Mr. 
Hargrave  seems,  therefore,  to  have  described  a  case  of  rupture  of  the 
long  head  of  the  biceps,  and  it  is  probable  that  Dupuytren,  who  knew 
nothing  of  the  previous  history  of  the  subject,  has  given  us  a  faithful 
account  of  a  pathological  dislocation,  a  result  of  disease,  and  not  of  a 
direct  injury. 

If  the  head  of  the  humerus  is  driven  from  its  socket  by  violence, 
and  remains  thus  displaced,  it  is,  we  assume,  a  complete  luxation; 
since  it  is  only  by  having  placed  the  semi-diameter  of  the  head  of  the 
bone  outside  of  the  margin  of  the  glenoid  fossa  that  it  can  be  made 
for  one  moment  to  retain  its  abnormal  position.  To  accomplish  this 
amount  of  displacement  upwards,  or  upwards  and  forwards,  or  directly 
forwards,  the  acromion  or  the  coracoid  processes  must  be  broken. 
While  its  occurrence  in  any  other  direction  must  involve  at  least  a 
most  extraordinary  extension,  if  not  an  actual  laceration  of  the  capsule. 
If  we  admit  with  Malgaigne  that  occasionally  the  capsule  has  been 
found  capable  of  such  extraordinary  extension  without  actual  rupture, 
we  still  are  unwilling  to  regard  this  as  a  fair  example  of  a  partial  dis- 
location, since  the  head  of  the  bone  no  longer  moves  in  its  socket, 
being  at  no  point  in  actual  contact  with  the  articular  surface  of  the 
glenoid  fossa.  It  is  essentially  a  complete  dislocation,  according  to  all 
the  admitted  definitions  of  this  term. 

It  is  quite  probable  that  a  majority  of  these  accidents  were  examples 
of  rupture  or  of  displacement  of  the  tendon  of  the  long  head  of  the 

biceps,  the  effect  of  which,  as  Mr, 
John  Gr.  Smith,^  and  Mr.  Soden^  have 
shown  by  a  number  of  dissections, 
is  to  allow  the  head  of  the  humerus 
to  be  drawn  upwards  and  forwards 
in  its  socket,  until  it  is  arrested  by 
the  two  processes,  and  by  the  co- 
raco-acromial  ligament.  Says  Mr. 
Soden  :  "To  enable  the  bone  to  main- 
tain its  equilibrium,  it  is  necessary 
that  the  capsular  muscles  should 
exactly  counterbalance  each  other; 
and  as  there  is  no  muscle  from  the 
ribs  to  the  humerus  to  antagonize 
the  upper  capsular  muscles"  (that  is, 
to  draw  the   head  of  the  humerus 

Displacement  ofthe  long  head  of  the  biceps.  doWUWards),     "it    is     SUggCStcd     that 


'  Amer.  Journ.  Med.  Sci.,  voL  xvi.  p.  219,  May,  1835,  from  Lond.  Med.  Gaz. 
2  Ibid.,  vol.  xxix.  p.  480,  from  Lond.  Med.  Gaz.,  July,  1841. 


PARTIAL    DISLOCATIONS    OF    THE    HUMERUS.  569 

this  office  is  performed  by  the  singular  course  of  the  long  tendon  of 
the  biceps,  which,  by  passing  over  the  head  of  the  bone,  when  the 
muscle  is  put  in  action,  tends  to  throw  the  head  downwards  and  back- 
wards ;  it  follows,  therefore,  that  the  tendon  being  removed,  the  head 
of  the  bone  would  rise  upwards  and  forwards." 

The  drawing  (Fig.  233)  represents  the  case  of  displacement  of  the 
tendon  of  the  biceps  seen  by  Mr.  Soden,  and  of  which  he  had  been 
permitted  to  make  a  dissection.^ 

I  have  myself  frequently  observed,  and  I  have  before,  when  speaking 
of  the  prognosis  or  results  of  dislocations,  called  attention  to  the  fact, 
that  the  head  of  the  humerus  sometimes  remains  for  a  long  time  after 
the  reduction  has  been  effected  slightly  advanced  in  its  socket,  so  as 
to  lead  to  a  suspicion  that  it  is  not  properly  reduced.  While  I  am 
writing,  two  additional  illustrations  have  come  under  my  notice,  in 
one  of  which  the  patient,  a  lad  of  about  fourteen  years  of  age,  had 
been  subjected  to  the  pulleys  during  four  consecutive  hours  to  accom- 
plish a  more  complete  reduction. 

The  same  thing,  also,  has  been  noticed  by  me  occasionally  where 
the  shoulder  had  been  subjected  to  a  violent  wrench,  but  no  actual 
dislocation  had  ever  occurred.  In  either  case  the  explanation  is  pro- 
bably the  same,  the  long  head  of  the  biceps  has  been  broken  or 
displaced.  I  mean  to  say  that  in  this  circumstance  we  may  find  a 
sufficient  and  perhaps  the  most  frequent  explanation;  yet  it  is  quite 
probable  that  in  a  considerable  number  of  cases,  the  laceration  of  the 
capsule,  and  the  action  of  the  muscles,  are  alone  concerned  in  the 
production  of  this  phenomenon. 

Alfred  Mercer,  of  Syracuse,  N.  Y,,  in  a  very  interesting  paper  on 
this  same  subject,  relates  several  examples  of  forward  displacement 
after  injuries  to  the  shoulder-joint,  one  of  which  as  being  exceedingly 
pertinent  I  shall  take  the  liberty  of  quoting. 

"Mrs.  B.,  a  well  developed  woman,  of  full  habit,  aged  fifty-six,  seven 
years  since  was  thrown  from  a  carriage,  dislocating  her  right  shoulder, 
which  was  reduced  a  short  time  after  the  accident,  but  the  shoulder 
was  painful,  and  tender  to  the  touch,  and  almost  useless  for  months 
after.  She  could  carry  the  arm  forwards  and  backwards,  but  could  not 
raise  it  from  the  side,  or  carry  the  hand  behind  her,  or  raise  it  to  her 
head,  for  fourteen  months.  She  has  gradually  gained  better  use  of 
her  arm,  but  now,  July,  1858,  she  cannot  raise  the  elbow  from  the 
side  more  than  half  way  to  a  horizontal  position  without  assistance, 
but  with  assistance,  the  arm  may  be  carried  into  any  position  without 
pain  or  resistance.  Measurement  shows  no  appreciable  difference  in 
the  size  or  length  of  the  arm,  or  size  of  the  shoulder;  but  the  point  of 
the  shoulder  is  still  tender  to  the  touch,  is  prominent  in  front,  and 
correspondingly  flattened  behind.  The  head  of  the  humerus  appears 
to  rest  against  the  outside  of  the  coracoid  process,  but  the  fulness  of 
habit  obscures  the  diagnosis,  compared  with  the  other  cases.  Several 
doctors,  at  different  times,  have  examined  the  shoulder;  some  have 
said  it  was  not  properly  reduced,  and  advised  a  suit  for  malpractice. 

'  Pirrie's  System  of  Surg.,  Amer.  ed.,  p.  255  ;  also,  Sir  Astley  Cooper,  edited  by 
Brausby  Cooper,  Amer.  ed.,  p.  363. 


570  DISLOCATIONS    OF    THE    HEAD    OF    THE    EADIUS. 

"I  examined  the  shoulder  again  in  November  last;  it  presented  the 
same  general  appearance,  although  the  patient  was  much  thinner  in 
flesh  from  recent  sickness.  Some  six  weeks  previous  to  this  exami- 
nation, in  a  sudden  and  thoughtless  effort  to  raise  the  arm  above  the 
head,  the  muscles  unexpectedly  obeyed  the  will;  since  which  time 
she  has  had  perfect  use  of  it,  though  the  deformity  still  remains.  She 
thinks  she  felt  or  heard  a  snap  when  the  arm  went  up,  but  it  was 
followed  by  no  pain,  soreness,  or  swelling.'" 

There  can  be  no  doubt,  we  think,  that  in  this  case  at  least,  the 
the  deformity  and  maiming  were  due  in  a  great  measure  to  a  dis- 
placement of  the  long  head  of  the  biceps. 


CHAPTER    VII. 

DISLOCATIONS   OF  THE  HEAD   OF  THE  EADIUS. 

I  HAVE  met  with  eighteen  examples  of  dislocation  of  the  head  of 
the  radius ;  of  which,  fourteen  were  dislocated  forwards  and  only  four 
backwards :  or,  rejecting  those  cases  which  were  complicated  with 
fracture,  I  have  recorded  eight  cases  of  simple  forward  luxation,  and 
two  of  simple  backward  luxation.  My  experience,  therefore,  does 
not  correspond  with  the  experience  of  Boyer,  Velpeau,  Yidal  (de 
Cassis),  Chelius,  B.  Cooper,  Guthrie,  Gibson,  and  some  others,  who 
declare  that  the  dislocation  backwards  is  the  more  frequent  of  the 
two.  Indeed,  I  ought  to  say  of  both  of  the  examples  of  backward 
luxation  of  the  radius  which  have  come  under  my  notice,  and  which 
I  have  marked  as  simple,  that  they  were  ancient  luxations,  and  I  am 
not  entirely  certain,  therefore,  that  they  had  not  been  originally  com- 
plicated with  a  fracture,  although  at  the  time  of  my  examination  they 
presented  no  such  evidence. 

§  1,  Dislocation  of  the  Head  of  the  Radius  Forwards, 

Causes. — A  fall  upon  the  elbow,  the  blow  being  received  directly 
upon  the  posterior  face  of  the  head  of  the  radius;  a  fall  upon  the 
hand  with  the  forearm  extended  and  pronated ;  extreme  pronation  of 
the  forearm ;  or,  according  to  Denuce,  a  blow  upon  the  inside  of  the 
elbow,  which  is  equivalent  to  a  violent  adduction  of  the  forearm. 

In  children,  and  especially  in  those  of  a  strumous  habit,  whose 
ligaments  are  feeble,  a  subluxation  forwards,  or  even  a  complete  luxa- 
tion, is  occasionally  produced  by  being  lifted  suddenly  from  the  floor 

'  Mercer,  Buffalo  Med.  Jourii.,  vol.  xiv.  p.  641,  April,  1859. 


DISLOCATION    OF    HEAD    OP    RADIUS    FORWAEDS. 


571 


by  the  hand  or  by  an  attempt  to  sustain  the  cbild  when  he  is  about 
to  fall,  I  have  seen  several  examples  of  this  latter  form  of  the  acci- 
dent produced  in  this  way.  Batchelder,'  Sylvester,^  Goyrand,^  and 
many  other  surgeons  have  mentioned  similar  cases. 

Dr.  Krackowitzer  related  to  the  New  York  Academy,  in  1856,  a 
case  of  complete  dislocation  forwards,  produced,  as  was  supposed,  in 
the  act  of  turning  the  child  in  delivery.  The  arm  was  ecchymosed, 
and  the  dislocation  was  very  distinct."* 

Pathological  Anatomy. — The  head  of  the  radius  is  carried  forwards 
upon  the  humerus,  and  sometimes  a  little  inwards  or  outwards ;  the 
anterior  and  external  lateral  liga- 
ments, with  the  annular,  are  gene-  Fig-  234. 
rally  more  or  less  broken.     Some-  , 
times   the   anterior   and    external 
lateral  are  alone  broken,  the  annu- 
lar ligament  being  then  sufficiently 
stretched  to  allow  of  the  complete 
dislocation ;    or   the   anterior   and 
annular   having    given    way,   the 
external  lateral  may  remain  intact. 

Symptoms. —  The  head  of  the 
radius  can  in  general  be  distinctly 
felt  in  its  new  situation,  rotating 
under  the  finger  when  the  hand  is 
pronated  and  supinated ;  we  may 
sometimes  also  recognize  a  depres- 
sion corresponding  to  its  natural 
situation,  behind  and  below  the  little 
head  of  the  humerus.  The  exter- 
nal border  of  the  forearm  is  slightly 
shortened,  and  the  arm  inclines 
unnaturally  outwards.  The  tendon 
of  the  biceps  is  relaxed.  The  fore- 
arm is  generally  pronated,  some- 
times it  is  in  a  position  midway 

between  supination  and  pronation,  but  I  have  never  seen  it  supinated. 
I  have  particularly  noticed  this  fact  in  my  report  made  to  the  New 
York  State  Medical  Society  in  1855,  and  Denuce,  who  has  also  exami- 
ned these  cases  carefully,  affirms  that  it  is  seldom  supinated,  notwith- 
standing the  general  statements  of  surgeons  to  the  contrary. 

The  arm  is  usually  a  little  flexed,  and  cannot  be  perfectly  extended 
without  causing  pain  ;  nor  can  it  be  flexed  much,  if  at  all,  beyond  a 
right  angle,  owing  to  the  impediment  offered  by  the  humerus,  against 
which  the  head  of  the  radius  now  impinges. 

Prognosis. — Denuc^  says,  "  The  reduction  is  often  impossible,  more 
frequently  still,  difficult  to  maintain."     In  proof  of  which  he  refers  to 

'  New  York  Journ.  Med.,  May,  1856,  p.  333. 

'^  Amer.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  206,  Jan.  1843. 

»  Ibid.,  vol.  xxxii.  p.  228,  .July,  1843. 

*  Krackowitzer,  New  York  Jouru.  Med.,  March,  1856,  p.  262. 


Head  of  radius  forwards.     Anatomical  relations. 


572 


DISLOCATIONS    OF    THE    HEAD    OF    THE    RADIUS. 


Fig.  235. 


the  observations  of  Danyau  and  Robert.  In  the  case  of  recent  luxa- 
tion related  by  Robert,  it  was  found  impossible  to  maintain  a  re- 
duction which  he  thought  he  had 
several  times  accomplished,  and  he 
believed  that  the  difficulty  consisted 
in  a  portion  of  the  torn  annular 
ligament  having  become  entangled 
between  the  head  of  the  radius  and 
the  condyle  of  the  humerus.^ 

Sir  Astley  Cooper  was  unable  to 
accomplish  the  reduction  in  two 
recent  cases ;  and  of  the  six  cases 
which  came  under  his  immediate 
observation,  only  two  were  ever 
reduced.  In  Bransby  Cooper's  edi- 
tion of  Sir  Astley's  work,  other 
similar  examples  of  non-reduction 
are  related. 

Malgaigne  says  that  in  a  collection 
of  twenty-five  cases  which  he  has 
made,  the  accident  was  unrecognized 
or  neglected  in  six,  and  ineffectual 
efforts  at  reduction  had  been  made 
in  eleven ;  so  that  only  eight  of  the 
whole  number  were  reduced. 

I  have  myself  met  with  five  of 
these  simple  dislocations  which  were 
not  reduced,  two  of  which,  however, 
had  not  been  recognized,  and  no 
attempts  at  reduction  had  ever  been 
made ;  one  had  been  treated  by  an 
empiric.  Sweet,  a  "  natural  bone-setter,"  but  without  success ;  one  had 
been  reduced,  but  it  had  become  reluxated,  and  in  the  remaining  ex- 
ample I  was  myself  unable  to  reduce  the  dislocation  on  the  seventh 
day. 

The  following  are  brief  notes  of  four  of  these  cases: — 
A  young  man,  get.  23,  presented  himself  at  my  office,  upon  whom 
the  accident  had  occurred  about  one  year  before.  The  surgeon  who 
was  first  called  did  not  recognize  the  dislocation,  and  no  attempt  had 
ever  been  made  to  replace  the  bones.  The  forearm  was  forcibly  pro- 
nated  and  could  not  be  supinated,  but  he  could  extend  it  completely, 
and  flex  it  somewhat  beyond  a  right  angle.  It  was  strong,  and  nearly 
as  useful  as  before. 

H.  H.  B.,  set.  6 ;  dislocation  produced  by  a  fall  upon  the  elbow. 
The  surgeon  who  was  called  did  not  detect  the  nature  of  the  injury. 
Eighteen  years  after,  I  found  the  head  of  the  radius  lying  in  front  of 
the  old  socket,  having  formed  a  new  socket  in  which  it  moved  freely. 
From  the  elbow  to  the  hand  the  arm  inclined  outwards,  or  to  the 


Head  of  radiu; 
ance  of  limb. 


forwards.     External  appear- 


•  Memoire  sur  les  Luxations  du  Coude,  par  Paul  Denucg.     Paris,  1854. 


DISLOCATION    OF   HEAD    OF    EADIUS    FORWAEDS.  573 

radial  side;  pronation  and  supination  were  perfect.  He  could  flex 
the  arm  to  an  acute  angle,  but  not  so  completely  as  the  other.  The 
arm  was  as  strong  as  the  other,  but  it  was  frequently  hurt  by  lifting, 

Ira  E.  Irish,  set.  12.  "Sweet"  was  at  first  employed,  but  failed  to 
reduce  it.  Thirty-nine  years  after,  when  Mr.  Irish  was  fifty-one  years 
old,  I  examined  the  arm.  He  could  not  flex  the  forearm  upon  the 
arm  beyond  a  right  angle ;  and  when  the  attempt  was  made,  the  radius 
struck  against  the  humerus.  Complete  supination  was  impossible. 
The  arm  was  as  strong  as  the  other  except  in  raising  a  weight  above 
his  head.     Occasionally  he  was  annoyed  with  slight  pains  in  this  limb. 

Urias  Lett,  a  colored  barber  of  Buffalo,  aged  forty-eight  years,  was 
thrown  from  a  carriage,  producing  a  dislocation  of  the  right  radius, 
and  severely  bruising  the  elbow-joint.  He  drove  a  couple  of  spirited 
horses  several  miles  after  the  accident,  and  did  not  see  Dr.  K.,  a  highly 
accomplished  young  surgeon,  until  six  hours  had  elapsed.  The  elbow 
was  then  much  swollen  and  exquisitely  tender,  and  Lett  would  not 
permit  much  if  any  examination,  to  enable  Dr.  K.  to  determine  his 
condition.  The  Dr.  applied  simple  dressings,  and  the  next  day  re- 
quested me  to  see  him.  The  whole  arm  was  then  swollen  and  tender, 
and  very  little  examination  was  admissible.  The  dressings  were, 
therefore,  not  completely  removed,  but  only  laid  open  sufficiently  to 
enable  us  to  see  the  joint.  We  suspected  a  forward  luxation  of  the 
head  of  the  radius,  but  could  not  positively  determine  the  point — the 
patient  not  permitting  any  kind  or  degree  of  manipulation.  We  de- 
cided, therefore,  to  wait  a  few  days,  until  the  inflammation  had  some- 
what abated,  and  then,  if  the  existence  of  a  dislocation  was  ascertained, 
to  attempt  its  reduction.  On  the  seventh  day  the  swelling  had  measur- 
ably subsided,  and  the  diagnosis  became  satisfactory.  We  immediately 
placed  him  under  the  complete  influence  of  chloroform,  and  made  long 
continued  and  violent  efibrts  at  reduction,  but  without  success.  Severe 
inflammation  again  followed  these  efforts,  and  Lett  would  never  con- 
sent to  another  trial.  After  four  years,  I  find  the  bone  still  out.  He 
can  flex  the  forearm  upon  the  arm  almost  as  far  as  he  can  the  opposite 
limb;  he  can  carry  it  nearly  to  his  mouth;  the  head  of  the  radius 
sliding  ofi*  upon  the  outer  face  of  the  humerus,  and  not  resting  plumply 
against  it;  indeed,  the  radius  seems  to  have  been  gradually  pushed 
outwards  as  well  as  forwards.  The  hand  is  forcibly  pronated,  and  can- 
not be  supinated.  The  attempt  to  supine  produces  a  click  in  the  neigh- 
borhood of  the  head  of  the  radius,  as  if  it  struck  against  a  bone.  The 
arm  is  as  strong  as  the  other,  and  not  wasted.  He  has  constantly  pur- 
sued his  occupation  as  a  barber,  after  only  a  few  weeks  confinement. 

If  the  dislocation  is  accompanied  with  a  fracture  of  the  ulna,  unless 
the  fracture  is  transverse  or  incomplete,  reduction  is  not  generally  ac- 
complished. When  speaking  of  fractures  of  the  shaft  of  the  ulna,  I 
have  related  several  examples  illustrative  of  this  remark.  Norris  has 
made  the  same  observation.^  I  have,  however,  three  times  met  with 
this  accident  thus  complicated  in  children,  in  the  treatment  of  which 
a  much  better  result  has  been  obtained.     In  the  first  example,  a  lad 

I  Norris,  Amer.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  21. 


574  DISLOCATIONS    OF   THE    HEAD    OF   THE    RADIUS. 

aged  nine  years  had  broken  the  ulna  in  its  upper  third  and  dislocated 
the  radius  forwards.  Dr.  White,  of  this  city,  and  myself  were  in  im- 
mediate attendance.  Both  the  fracture  and  dislocation  were  easily  re- 
duced, and  in  a  few  weeks  the  limb  was  sound  and  perfect,  except  that 
a  slight  fulness  remained  in  front  of  the  head  of  the  radius,  and  this 
continued  for  several  years.  In  the  second  example,  a  lad  of  the  same 
age  as  the  other,  was  treated  by  Dr.  Austin  Flint  and  myself.  We 
reduced  both  the  fracture  and  the  dislocation  by  extending  the  arm 
from  the  wrist,  while  at  the  same  moment  pressure  was  made  upon  the 
head  of  the  radius  from  before  backwards.  A  right  angled  splint  was 
applied  and  continued  during  a  period  of  four  weeks,  being  removed 
daily  for  the  purpose  of  giving  to  the  joint  gentle,  passive  motion,  &c. 
After  this  the  arm  was  permitted  to  straighten  gradually,  and  at  the 
end  of  a  month  more,  the  joint  was  moving  freely,  and  with  no  degree 
of  displacement  at  the  point  of  fracture  or  dislocation. 

It  is  quite  probable  that  in  each  of  the  above  cases  the  separation 
was  not  complete,  although  crepitus  was  distinct,  and  the  displacement 
of  the  broken  ends  was  very  marked.  In  the  following  case  the  frac- 
ture was  certainly  incomplete : — 

Elizabeth  Carmody,  set.  4,  was  brought  to  me,  August  6, 1851,  with 
a  fracture  of  the  ulna,  two  inches  below  its  upper  end,  the  fragments 
being  inclined  backwards,  while  the  radius  was  dislocated  forwards. 
Both  bones  were  easily  replaced,  and  the  functions  of  the  arm  were 
soon, completely  restored.' 

Where  the  restoration  has  been  promptly  effected  and  maintained 
steadily,  the  motions  of  the  joint  are  soon  restored;  but  in  one  case 
the  head  of  the  radius  has  been  found  to  play  very  freely  and  loosely 
after  the  lapse  of  two  years,  and  in  others  it  has  remained  slightly 
prominent  in  front,  as  if  it  was  a  little  in  advance  of  its  socket. 

Treatment. — Extension  and  counter-extension  should  be  made  in  the 
direction  in  which  we  alread}'  find  the  limb,  namely,  with  the  forearm 
slightly  bent  upon  the  arm,  while  at  the  same  moment  the  surgeon 
should  seize  the  elbow  with  his  hands,  and  press  the  head  of  the  radius 
back  with  his  two  thumbs. 

Other  methods  will  often  succeed ;  but  by  this  we  relax  the  biceps, 
and  put  the  parts  in  the  best  position  to  accomplish  the  reduction 
easily  and  promptly.  Sir  Astley  directed  to  supine  the  forearm  while 
the  extension  was  being  made  from  the  hand,  but  Denuc^  prefers  that 
the  forearm  should  be  in  a  position  of  pronation. 

After  the  reduction  is  efiected  it  is  never  safe  to  straighten  the  arm 
completely  at  once,  nor  indeed  for  some  weeks;  not  until  the  ligaments 
have  been  sufficiently  restored  to  resist  the  action  of  the  biceps.  The 
arm  must  therefore  be  flexed  and  placed  in  a  sling,  or,  if  the  radius  is 
disposed  to  become  reluxated,  a  right-angled  splint  ought  to  be  placed 
upon  the  back  of  the  arm  and  forearm,  and,  by  the  aid  of  a  compress 
and  roller,  an  attempt  should  be  made  to  retain  it  in  place. 

Nor  will  it  be  found  safe  at  any  period  to  compel  the  arm  by  force 

'  This  case  was  erroneously  reported  to  the  N.  Y.  State  Medical  Society  as  an 
example  of  fracture  of  the  radius,  with  dislocation. 


DISLOCATION    OF    HEAD    OF    RADIUS    BACKWARDS.         575 

to  resume  the  straight  position,  since  this  bone,  when  it  has  once  been 
dislocated,  will  for  a  long  time  be  liable  to  luxation. 

A  boy,  aged  about  four  years,  was  presented  at  my  clinic  by  his 
father,  having  a  forward  dislocation  of  the  head  of  the  radius.  The 
dislocation  still  existed  after  several  months.  The  father's  purpose  in 
bringing  the  child  was  to  ascertain  whether  he  could  not  claim  damages 
for  malpractice.  The  account  which  he  gave  was  as  follows :  The 
surgeon  called  it  a  dislocation  forwards,  and  pretended  to  reduce  it. 
A  right-angled  splint  was  applied,  with  a  roller.  At  the  end  of  three 
weeks  the  father  removed  the  splint,  but  did  not  discover  anything  out 
of  place.  Finding,  however,  that  the  elbow  was  stiff,  he  took  measures 
to  straighten  it  forcibly.  In  a  few  days  he  discovered  the  head  of  the 
bone  out  of  place,  and  so  it  has  remained  ever  since. 

I  explained  to  him  that  there  was  much  reason  to  suppose  that  the 
surgeon  had  properly  reduced  the  dislocation,  and  that  he  had  himself 
reproduced  the  accident,  by  straightening  the  arm,  through  the  action 
of  the  biceps  upon  the  upper  end  of  the  radius.  The  father  declined 
any  further  surgical  interference,  and  no  prosecution  has  followed. 

Dr.  Batchelder,  of  Xew  York,  in  a  very  excellent  paper  on  dislocations 
of  the  head  of  the  radius,  describes  a  method  of  reduction  suggested 
to  him  first  by  Dr.  Goodhue,  of  Chester,  Vermont,  and  which  he  has 
himself  found  more  successful  than  any  other  method;  indeed,  he  says 
it  never  fails,  yet  he  does  not  inform  us  in  precisely  how  many  cases 
he  has  made  the  trial.  The  plan  suggested  by  Dr.  Goodhue  consists 
essentially  in  first  making  extension  from  the  hand,  and  pressing  at 
the  same  time  downwards  and  backwards  upon  the  head  of  the  radius 
until  it  has  descended  to  a  level  with  the  articulating  surface  of  the 
humerus.  As  soon  as  this  is  accomplished,  the  forearm  is  to  be  sud- 
denly flexed  upon  the  arm  in  such  a  direction  as  that  the  hand  shall 
pass  outside  of  the  shoulder ;  at  the  same  moment,  also,  the  pressure 
must  be  continued  vigorously  upon  the  head  of  the  radius.^ 


§  2.    DlSLOCATIOX  OF  THE  HeAD  OF  THE  RADIUS  BACKWARDS. 

Denuce  has  collected  fourteen  examples  of  this  luxation;  but  Mal- 
gaigne,  who  rejects  a  portion  of  these  cases,  and  adds  one  or  two  more, 
admits  only  twelve.  In  addition  to  those  mentioned  by  these  two 
writers,  I  have  found  recorded,  or  incidentally  noticed,  one  by  May,^ 
one  by  Bransby  Cooper,^  one  by  Lawrence,"*  one  by  Liston,*  two  by 
Case,^  two  by  Gibson,^  one  by  Parker,^  three  by  Markoe,^  and  to  these 

'  Goodhue,  New  York  Journ.  of  Med.,  May,  1856,  p.  333. 
^  May,  Sir  Astley  Cooper  on  Dislocations,  &c.,  by  B.  Cooper,  op.  cit.,  p.  4^i3. 
3  B.  Cooper,  ibid.,  p.  404. 

*  Lawrence,  Pirrie's  System  of  Surgery,  p.  259.         ^  Liston,  Practical  Surgery,  p.  88. 
"  Case,  Amer.  Journ.  of  Med.  Sci.,  vol.  vi.  p.  254,  from  11th  No.  of  Provincial  Med. 
Gazette. 

"  Gibson,  Institutes  and  Practice  of  Surgery,  6th  ed.,  vol.  i.  p.  379. 
^  Parker,  New  York  Journ.  of  Med.,  March,  1852,  p.  188. 
»  Markoe,  ibid.,  May,  1855,  p.  382. 


676  DISLOCATIONS    OF    THE    HEAD    OP    THE    EADIUS. 

ray  own  observatioas  have  added  four  more,  in  all  twenty-eight  sup- 
posed examples. 

Of  the  examples  brought  under  my  own  notice  I  have  already  in 
the  preceding  section  affirmed  that  two  of  them  were  accompanied 
with  fracture,  and  I  am  not  entirely  certain  but  that  they  all  were. 
Markoe,  of  New  York,  whom  we  have  mentioned  as  having  reported 
three  cases,  found  in  each  case  a  fracture  of  the  internal  condyle  of 
the  humerus,  and,  after  an  examination  of  a  number  of  the  reported 
examples,  he  does  not  find  any  evidence  that  this  dislocation  ever 
occurs  as  a  simple  uncomplicated  accident.  I  am  unable  to  complete 
the  critical  analysis  which  Dr.  Markoe  has  undertaken;  yet  I  confess 
that,  so  far  as  I  have  been  able  to  do  so,  the  testimony  strongly  con- 
firms his  conclusions.  While  I  am  prepared  to  admit  the  possibility 
of  the  luxation  without  either  a  fracture  of  the  lower  end  of  the 
humerus  or  of  the  ulna,  I  have  found  no  written  account  of  any  case, 
nor  have  I  seen  an  example,  which  was  absolutely  conclusive. 

The  example  reported  by  Parker  as  having  occurred  in  the  practice 
of  N.  K.  Freeman,  of  New  York,  is  one  of  the  few  which  seems  to 
admit  of  but  very  little  doubt. 

In  July,  1850,  Dr.  Freeman  was  called  to  see  a  gentleman,  set.  37, 
who  was  seriously  injured  by  jumping  from  the  railroad  cars  while 
they  were  in  motion,  and  found  a  backward  luxation  of  the  head  of 
the  radius  of  the  right  arm.  "  The  symptoms,"  says  Dr.  Freeman, 
"wer^  marked;  the  hand  and  forearm  were  prone,  and  the  attempt  to 
place  them  in  the  supine  position  caused  great  pain;  while  the  head  of 
the  radius  formed  a  considerable  projection  posterior  to  the  external 
condyle  of  the  humerus,  where  the  cavity  on  its  extremity  could  be  dis- 
tinctly felt.  Assisted  by  Dr.  Walsh,  of  Fordham,  who  firmly  grasped 
the  humerus,  I  was  enabled  to  reduce  it  by  extending  the  forearm  and 
flexing  it  upon  the  arm,  at  the  same  time  pronating  the  hand,  and 
pressing  forwards  the  head  of  the  radius  with  my  thumb.  After  the 
reduction  was  effected,  I  requested  Dr.  Walsh  to  examine  it ;  when, 
upon  slight  extension  being  made  upon  the  forearm,  with  supination 
of  the  hand,  the  bone  was  again  dislocated.  I  immediately  reduced 
it  in  the  same  manner  as  before,  and  directed  the  patient  to  keep  the 
forearm  flexed  and  the  hand  prone,  and,  laying  it  upon  a  pillow,  apply 
cold  water.  He  complained  of  severe  pain  for  two  days,  which  gradu- 
ally subsided,  and  on  the  fourth  day  he  was  able  to  move  and  extend 
the  forearm." 

Causes. — A  direct  blow  upon  the  front  and  upper  part  of  the  radius ; 
a  fall  upon  the  elbow,  or  upon  the  hand;  a  violent  effort  to  supine  the 
forearm  while  it  is  grasped  and  held  firmly  in  a  state  of  pronation ; 
probably,  also,  sometimes  it  is  occasioned  by  a  twisting  of  the  arm  in 
machinery,  &c. 

Pathological  Anatomy. — In  the  only  example  of  which  a  dissection 
has  been  made,  reported  by  Sir  Astley  Cooper,  "  the  coronary  liga- 
ment was  found  to  be  torn  through  at  its  forepart,  and  the  oblique 
had  given  way.  The  capsular  ligament  was  partially  torn,  and  the 
head  would  have  receded  much  more,  had  it  not  been  supported  by 
the  fascia  which  extends  over  the  muscles  of  the  forearm."     The  head 


DISLOCATION    OF    HEAD    OF    RADIUS    OUTWAKDS. 


577 


Fig.  236. 


of  the  radius  was  thrown  behind  the  external  condyle  of  the  humerus, 
and  rather  to  the  outer  side.  This  was  an  ancient  luxation  found  in 
the  dissecting-room  of  St.  Thomas's  Hospital,  and  the 
accompanying  drawing  is  copied  from  the  sketch 
made  at  the  time. 

If  the  luxation  is  not  complete,  as  occasionally 
happens  with  children,  the  annular  ligament  may  not 
be  torn. 

Symptoms. — The  head  of  the  bone  is  felt  rotating 
behind  the  outer  condyle,  and  a  depression  exists 
corresponding  to  its  original  position.  The  forearm  is 
slightly  flexed  and  prone  ;  and  the  whole  arm  is  de- 
flected outwards  from  the  elbow  downwards;  flexion 
and  extension  are  difficult,  while  supination  is  im- 
possible. 

Treatment. — Most  surgeons  have  agreed  that  while 
extension  and  counter-extension  are  being  made,  the 
forearm  should  be  forcibly  supinated.  At  the  same 
time,  also,  the  head  of  the  radius  must  be  strongly 
pushed  forwards.  Martin  recommends  to  extend 
forcibly,  and  then  suddenly  flex  the  arm,  in  a  manner 
very  similar  to  the  plan  recommended  by  Batchelder 
in  dislocations  forwards.  In  Dr.  Freeman's  case,  just 
quoted,  the  reduction  was  efiected  while  the  forearm 
was  prone,  and  supination  seemed  to  throw  it  again 
out  of  place. 

According  to  Markoe,  where  the  accident  is  complicated  with  a 
fracture  of  the  inner  condyle,  when  the  reduction  is  accomplished  the 
arm  should  be  placed  in  a  position  about  ten  degrees  less  than  a  right 
angle,  and  supported  by  a  splint  with  bandages,  &c. 

If  the  dislocation  is  simple,  however,  I  can  see  no  objections  to  its 
being  nearly  or  quite  extended,  since  in  this  dislocation  the  action  of 
the  biceps  would  only  tend  to  retain  the  head  of  the  radius  in  place. 


Dislocation  of  the 
head  of  the  radius 
backwards. 


§  3.  Dislocation  of  the  Head  op  the  Radius  Outwards. 

Denuc^  has  collected  four  examples  of  this  accident,  unaccom- 
panied with  a  fracture,  and  he  proceeds  to  speak  of  it  as  a  distinct 
form  of  dislocation.  In  two  of  the  examples,  however,  mentioned  by 
him,  it  was  consecutive  upon  a  forward  luxation,  and  I  have  several 
times  seen  the  head  of  the  radius  very  much  inclined  outwards  in  what 
are  properly  termed  forward  dislocations.  For  these  reasons  it  is  not 
very  plain  to  me  that  we  ought  to  consider  this  even  as  a  distinct  form 
of  primary  dislocation,  but  rather  as  a  consecutive  luxation,  or  at  least 
as  only  a  modification  of  the  forward  or  backward  luxation.  Indeed, 
I  think  the  radius  never  will  be  found  thrown  directly  outwards,  but 
always  in  a  direction  inclining  forwards  or  backwards. 

Parker,  of  New  York,  mentions  a  case  which  came  under  his  notice, 
in  a  child  four  years  old,  who  six  weeks  before,  had  fallen  down  stairs 
37 


578      DISLOCATIONS    OF    UPPER   END    OF    ULNA   BACKWARDS. 

"  backwardly,  with,  the  right  arm  twisted  behind  the  back,  in  such  a 
position  that  the  whole  weight  of  her  body  came  upon  her  arm."  No 
attempt  was  ever  made  to  reduce  the  bone,  and  the  head  of  the  radius 
continued  to  project  externally.  By  pressure  it  was  easily  reduced, 
but  became  immediately  displaced  when  the  forearm  was  either  flexed 
or  extended.  The  motions  of  the  joint  were  completely  restored.  Dr. 
Parker  recommended  no  treatment.^ 


CHAPTER    VIII. 

DISLOCATIONS   OF  THE  UPPER  END   OF  THE  ULNA 
BACKWARDS. 

This  accident,  the  existence  of  which  as  a  simple  luxation,  is 
rendered  probable  by  a  certain  number  of  cases,  has  nevertheless  been 
described  so  variously  and  often  indefinitely,  that  it  is  impossible  to 
declare  its  history,  except  in  a  few  points,  with  any  degree  of  accuracy. 
No  doubt  many  of  the  cases  which  have  been  reported  were  examples 
only  of  a  subluxation  of  both  radius  and  ulna  backwards.  In  other 
cases  the  radius  or  the  external  condyle  of  the  humerus  being  broken, 
the  ulna  has  been  actually  displaced,  not  only  backwards  but  upwards; 
indeed  it  is  very  certain  that  without  either  a  luxation  of  the  radius, 
or  a  fracture  with  displacement  of  the  external  condyle  of  the  humerus, 
or  a  fracture  or  bending  of  the  radius,  an  upward  displacement  of 
the  ulna,  to  the  degree  represented  by  the  reporters  of  these  cases, 
could  never  have  occurred.  The  example  mentioned  by  Sir  Astley 
Cooper,  and  of  which  a  dissection  was  made,  is  plainly  a  case  of  sub- 
luxation of  both  bones;  or  if  the  luxation  of  the  ulna  may  be  regarded 
as  having  been  complete,  the  head  of  the  radius  was  also  displaced 
more  or  less  upwards  from  its  original  socket,  a  new  socket.  Sir  Astley 
himself  informs  us,  having  been  formed  for  its  reception,  upon  the 
external  condyle.  But  this  is  the  only  example,  the  actual  condition 
of  which  has  been  proven  by  an  autopsy. 

Nevertheless  it  seems  possible  that  a  simple  luxation,  or  subluxa- 
tion of  the  ulna  backwards,  may  occur  without  either  of  the  above 
mentioned  complications,  and  that,  to  the  extent  of  a  few  lines,  it  may 
be  made  to  pass  upwards  upon  the  back  of  the  humerus,  by  the  falling 
of  the  forearm  to  the  ulnar  side ;  in  which  case  the  character  of  the 
accident  would  probably  be  recognized  by  the  projection  of  the  ole- 
cranon process,  while  the  head  of  the  radius  might  be  felt  moving  in 
its  socket — by  the  partial  flexion  and  complete  pronation  of  the  fore- 
arm, and  by  the  general  immobility  of  the  joint. 

1  Parker,  New  York  Journ.  Med.,  March,  1852,  p.  189. 


DISLOCATION    OF    RADIUS    AND    ULNA    BACKWARDS. 


579 


Its  reduction  ought  to  be  accomplished  easily  by  the  same  measures 
which  have  been  found  successful  in  reducing  a  dislocation  of  both 
bones  backwards. 

Fig.  237. 


Dislocation  of  the  upper  end  of  the  ulna  backwards. 

Pirrie  says  that  in  a  case  occurring  in  the  practice  of  ]\Ir.  Gosset, 
in  which  the  coronoid  process  rested  on  the  internal  condyle,  and  the 
pain  on  bending  the  arm  was  insupportable,  owing,  it  was  supposed, 
to  the  pressure  of  the  coronoid  process  against  the  ulnar  nerve,  "re- 
duction was  accomplished  by  extension  and  counter-extension  applied 
by  two  persons  pulling  in  opposite  directions,  aod  by  the  pressure  of 
the  olecranon  process  downwards  and  outwards,  while  the  forearm 
was  suddenly  flexed."* 


CHAPTER    IX. 

DISLOCATIOXS    OF    THE   RADIUS    AND    ULNA    (FORE- 
ARM   AT  THE  ELBOW-JOINT.) 

The  radius  and  ulna  may  be  dislocated  at  the  elbow-joint,  back- 
wards;  laterally,  that  is,  either  inwards,  or  outwards;  and  forwards. 


§  1.  Dislocations  of  the  Radius  and  Ulna  Backwards. 

Causes. — In  thirty-three  cases  observed  by  me,  the  average  age  is 
about  nineteen  years ;  the  youngest  being  four  years  old,  and  the 
oldest  fifty-three.  Nineteen  of  this  number  occurred  in  children  under 
fourteen  years  of  age. 

Generally  the  dislocation  has  been  produced  by  a  fall  upon  the  palm 
of  the  hand,  as  when  in  running  a  person  has  fallen  forwards  with  the 
forearm  extended  in  front  of  the  body,  or  he  may  have  fallen  from  a 
height ;  once  I  have  known  it  produced  by  a  blow  received  upon  the 
back  and  lower  part  of  the  humerus. 

'  Gosset,  Pirrie's  Surg.,  Amer.  ed.,  p.  259. 


580 


DISLOCATIONS    OF.  THE    RADIUS   AND    ULNA. 


Fig.  238. 


It  is  said  also  to  be  produced  occasionally  by  twisting  the  forearm 
violently,  as  when  the  limb  has  been  caught  and  wrenched  about  by 
machinery,  by  a  blow  upon  the  front  and  upper  part  of  the  forearm, 
and  by  forced  flexion. 

Pathology. — The  radius  and  ulna  are  not  only  carried  backwards  be- 
hind the  articulating  surface  of  the  humerus,  but  they  are  also,  through 
the  action  of  the  triceps,  almost  always  drawn  more  or  less  upwards, 
so  that  often  the  coronoid  process  of  the  ulna  rests  in  the  olecranon 

fossa.  In  some  cases  it  has  been  known  to 
mount  even  higher,  while  in  others  it  is 
arrested  short  of  this  point.  The  radius 
still  retaining  its  relative  position  to  the 
ulna,  lies  upon  the  back  of  the  humerus,  or 
rather  upon  the  posterior  margin  of  its 
articulating  surface. 

The  anterior  and  two  lateral  ligaments 
are  generally  more  or  less  completely  torn 
asunder;  but  the  posterior  ligament  and 
the  annular  do  not  usually  suffer  disrup- 
tion. 

The  biceps  muscle  is  drawn  over  the 
lower  articulating  surface  of  the  humerus, 
but  is  in  a  condition  of  only  moderate 
tension,  while. the  brachialis  anticus  is  forci- 
bly stretched  or  even  torn. 

The  median  nerve  is  also  pressed  upon 
in  front  by  the  humerus,  and  the  ulnar  is 
occasionally  painfully  stretched  over  the  projecting  extremity  of  the 
ulna  from  behind. 

Symptoms. — Sir  Astley  Cooper  does  not  mention  particularly  the 
position  of  the  arm  as  to  flexion  or  extension,  except  to  say  that  "  the 
flexion  of  the  joint  is  in  a  great  degree  lost ;"  nor,  in  his  original  work, 
published  in  London  in  1823,  is  there  any  illustration  accompanying 
the  text  to  indicate  in  what  position  he  had  usually  seen  the  limb ;  but 
in  the  later  editions,  edited  by  Mr.  Bransby  Cooper,  is  f6und  a  drawing 
which  represents  the  forearm  at  a  right  angle  with  the  arm.  It  is  very 
certain  that  Sir  Astley  never  sanctioned  this  error  by  anything  which 
he  had  written  or  communicated  to  others.  It  is  very  certain,  I  say, 
because,  the  fact  that  it  seldom,  if  ever,  occupies  this  position  could 
not  have  escaped  the  notice  of  one  whose  experience  was  so  large,  and 
whose  habits  of  observation  were  generally  so  accurate.  The  truth  is 
that  it  is  almost  constantly  found  only  slightly  flexed,  or  forming  an 
angle  in  front  of  about  120°. 

This  fact  is  especially  noticed  in  my  records  twenty-one  times,  and 
if  it  had  ever  been  found  in  any  other  position  it  would  certainly  have 
been  stated.  Once,  where  the  dislocation  was  accompanied  with  a 
fracture  of  the  outer  condyle  of  the  humerus,  the  arm  was  at  first 
straight,  a  position  in  which  it  is  said  to  be  found  occasionally  with 
children,  but  never  in  any  instance  have  I  found  it  flexed  to  a  right 
angle ;  yet  I  will  not  deny  that  such  unusual  phenomena  are  possible ; 


Dislocation  of  the  radius  and  ulna 
backwards. 


I 


DISLOCATION"    OF    RADIUS    AND    ULNA    BACKWARDS.       581 

indeed,  it  is  certain  that  they  have  occasionally  been  presented,  but 
they  must  be  regarded  as  only  exceptional,  and  as  by  no  means  diag- 
nostic of  this  accident. 

Sir  Astley  Cooper  and  Miller  declare  that  in  this  dislocation  the 
forearm  is  usually  supine ;  Pirrie  says :  "  The  hand  is  between  prona- 
tion and  supination,  but  more  inclined  to  the  latter,;"  Desault  thinks  it 
is  sometimes  in  supination  and  sonietimes  in  pronation;  Denuce  con- 
cludes that  it  will  occupy  that  position,  whatever  it  may  be,  in  which 
the  force  of  the  blow  has  thrown  it ;  while  by  most  surgical  writers  no 
allusion  is  made  to  the  position  of  the  forearm  in  reference  to  prona- 
tion or  supination.  For  myself,  I  can  only  say  that  I  have  found  the 
forearm  ^nd  hand  constantly  in  a  position  of  moderate,  but  positive, 
pronation,  and  I  am  compelled  to  regard  it,  therefore,  as  one  of  the 
usual  signs  of  a  backward  dislocation  of  these  bones. 

The  limb  can  be  neither  flexed  nor  extended  without  force,  and 
such  motion  is  almost  always  accompanied  with  pain.  It  is,  however, 
possible  in  most  cases  to  give  to  the  arm  a  slight  lateral  motion,  such 
as  does  not  belong  to  it  in  its  natural  condition. 

In  front  and  deep  in  the  fold  of  the  elbow  is  felt  the  lower  end  of 
the  humerus,  forming  a  hard,  broad,  and  somewhat  irregular  projec- 
tion, over  which  the  integuments  and  muscles  are  swollen,  and  tender 
to  pressure.  Behind,  the  head  of  the  radius  may  be  felt,  when  not 
much  tumefaction  exists,  rotating  or  moving  under  the  finger  when  the 
forearm  is  supinated  and  pronated  ;  while  the  olecranon  process  pro- 
jects strongly  backwards  and  upwards.  If  now  we  flex  the  arm 
slightly,  this  projection  of  the  olecranon  process  will  be  sensibly 
increased;  but  if  an  attempt  is  made  to  straighten  the  arm,  it  will  be 
diminished,  the  reverse  of  what  we  have  seen  to  happen  in  cases  of 
fracture  of  the  lower  end  of  the  humerus  (at  the  base  of  the  condyles). 
This  circumstance  becomes,  therefore,  an  important  diagnostic  mark 
between  these  two  accidents. 

The  relation  of  the  olecranon  process  also  to  the  condyles  is  changed, 
and  the  upper  end  of  this  process,  instead  of  being  a  little  below  the 
internal  condyle,  as  it  would  be  naturally  when  the  arm  is  slightly  flexed, 
is  found  generally  carried  upwards  toward  the  shoulder,  from  half  an 
inch  to  one  inch  or  more  above  the  condyle. 

Measuring  from  the  internal  condyle  to  the  styloid  process  of  the 
ulna,  the  arm  is  shortened ;  the  same  result  will  be  obtained  also  by 
measuring  from  the  acromion  process,  to  either  of  the  styloid  pro- 
cesses ;  while  from  the  acromion  process  to  the  condyle,  the  length 
will  be  the  same  in  both  arms. 

The  signs  which  have  now  been  enumerated  will  be  sufficient  to 
enable  us  to  make  the  diagnosis  promptly  in  the  great  majority  of 
cases,  but  if  considerable  swelling  has  already  taken  place,  the  diag- 
nosis may  be  rendered  exceedingly  difficult,  if  not  impossible ;  and  in 
such  cases  we  should  confine  the  patient  at  once  to  his  bed,  and  pro- 
ceed to  reduce  the  tumefaction  by  cool  water  lotions  as  rapidly  as 
possible,  examining  the  limb  carefully  from  day  to  day  in"  order  that 
we  may  seize  the  earliest  opportunity  to  ascertain  its  actual  condition 
and  apply  the  proper  remedy. 


582  DISLOCATIONS    OF    THE    EADIUS    AND    ULNA. 

In  relation  to  the  difficulty  of  diagnosis  in  certain  examples  of  this 
accident,  and  under  certain  circumstances,  Mr.  Skey,  in  his  Operative 
Surgery,  has  made  some  very  judicious  remarks. 

"  Severe  injuries  of  the  elbow-joint,  whether  in  the  form  of  fracture, 
dislocation,  or  a  compound  of  the  two,  are  frequently  followed,  at  a 
short  interval,  by  swelling  of  a  formidable  kind,  in  wlaich  it  is  impos- 
sible, but  by  the  aid  of  a  perfect  intimacy  with  the  anatomical  struc- 
ture of  the  joint,  to  detect  the  relations  of  one  part  with  another;  but 
even  under  this  difficulty,  the  two  points  in  question  are  readily  dis- 
tinguishable. In  such  forms  of  swelling,  the  arm,  including  the  length 
of  six  inches  both  above  and  below  the  joint,  may  be  involved  in  the 
extravasation,  and  this  swelling  may  distend  the  arm  to  a  circumfer- 
ence of  one-third  beyond  its  natural  size.  In  such  circumstances,  in 
which  it  is  impossible  to  determine  with  any  certainty  whether  any, 
or  what  bones  are  broken,  or  whether  or  not  dislocated,  the  difficulty 
of  the  case  should  at  once  be  stated  to  the  friends  of  the  patient." 

Prognosis. — If  the  luxation  is  recent,  reduction  is  in  general  easily 
effected,  but  if  considerable  time  has  elapsed,  the  reduction  is  often 
accomplished  with  difficulty.  As  to  the  probability  of  its  reluxation, 
I  have  already  spoken  when  considering  the  subject  of  fractures  of  the 
coronoid  process.  Unless  this  process  is  broken,  it  is  not  likely  to 
occur  except  where  some  violence  has  again  been  applied.  It  has 
happened  to  me,  however,  to  find  these  bones  unreduced  in  several 
instances.  In  some  of  these  examples  surgeons  recognized  the  acci- 
dent and  supposed  that  they  had  accomplished  reduction,  while  in 
others  the  dislocation  was  mistaken  for  a  fracture. 

A  lad,  W.  F.,  twelve  years  old,  residing  in  this  county,  was  brought 
to  me  six  weeks  after  the  accident  had  occurred.  The  surgeon  who 
was  first  called  declared  it  to  be  a  dislocation,  and  told  the  parents  he 
had  reduced  it;  but  the  dislocation  was  now  complete,  and  the  arm 
immovably  fixed  in  its  abnormal  position. 

On  the  tenth  of  May,  1850,  J.  P.,  of  Canada  West,  set.  25,  was 
thrown  from  a  load  of  hay,  striking  upon  his  left  hand,  and  producing 
a  dislocation  backwards  of  both  bones  at  the  elbow-joint.  A  Canadian 
surgeon,  who  saw  the  patient  within  three  hours,  recognized  the  dislo- 
cation, and  by  pulling  the  arm  straight  forwards  he  supposed  he  had 
reduced  it ;  the  patient  also  thought  he  felt  the  bones  slip  into  place. 
No  attempt  was  made  subsequently  to  flex  the  arm,  and  it  was  imme- 
diately dressed  with  a  straight  splint  laid  along  the  palmar  surface. 
On  the  sixth  day  it  was  found  to  be  unreduced,  and  the  surgeon  again 
attempted  to  reduce  it  as  before,  and  thought  he  had  succeeded.  The 
same  splint  was  reapplied.  At  about  the  end  of  six  weeks  three 
surgeons,  residing  in  Canada  also,  placed  the  patient  under  the  com- 
plete influence  of  chloroform,  and  attempted  the  reduction.  They  first 
made  extension  for  half  an  hour  in  a  straight  line,  then  five  men 
seized  upon  the  arm  and  forearm,  bending  it  with  great  force  to  a  right 
angle.  It  was  now  believed  that  the  ulna  was  reduced,  but  not  the 
radius.  I^ur  days  after,  the  attempt  was  renewed.  Three  months 
after  the  accident  the  young  man  called  upon  me,  and  I  found  the  arm 
nearly  straight,  with  almost  complete  anchylosis  at  the  elbow-joint 


DISLOCATION    OF    RADIUS    AXD    UL>^A    BACETTAEDS.        583 

Botli  the  radius  and  ulna  were  displaced  backwards,  but  not  upwards. 
The  arm  was  of  the  same  length  with  the  other,  and  the  relation  of 
the  condyles  to  the  olecranon  was  so  manifest,  that  the  absence  of  the 
usual  displacement  upwards  was  easily  determined.  I  was  unwilling 
to  make  any  further  attempts  at  reduction,  not  believing  that  I  should 
succeed  after  so  much  time  had  elapsed,  and  after  so  many  ineffectual 
attempts  had  been  made  by  clever  surgeons. 

In  the  following  examples  the  dislocation  was  supposed  to  have 
been  a  fracture  of  the  lower  end  of  the  humerus. 

A  man,  residing  in  Pittsfield,  Mass.,  dislocated  his  left  arm  by  fall- 
ing from  a  horse.  The  surgeon  who  was  called  regarded  it  as  a  frac- 
ture at  the  base  of  the  condyles,  and  treated  it  accordingly.  Ten 
weeks  after,  the  error  was  discovered  and  an  attempt  was  made  to 
reduce  it,  but  without  success.  A  second  attempt  was  also  made  with 
the  same  result. 

The  patient  was  brought  to  me  eight  months  after  the  accident  with 
the  bones  still  unreduced.  The  forearm  hung  at  a  very  obtuse  angle 
with  the  arm,  and  there  was  very  slight  motion  at  the  elbow-joint.  I 
discouraged  any  further  attempts  at  reduction. 

^[r.  W.,  of  Alleghany  Co.,  jST.  Y.,  £et.  43,  fell  from  a  load  of  hay 
striking  upon  his  left  arm,  Feb.  16,  1853.  Four  hours  after  he  was 
seen  by  a  young,  but  very  intelligent  surgeon,  who  thought  the  humerus 
was  broken  just  above  the  condyles.  After  eight  weeks,  the  fact  that 
it  was  a  dislocation  having  become  apparent,  three  surgeons,  well 
known  to  me  as  men  of  large  experience,  attempted  its  reduction, 
aided  by  pulleys  and  chloroform.  The  patient  was  also  bled  and  nau- 
seated with  antimony.  The  efforts  were  protracted  through  many 
hours,  and  frequently  varied.  A  second  attempt  made  by  these  same 
gentlemen  a  few  days  after  was  equally  unsuccessful. 

On  the  ninth  week  Mr.  W.  came  to  me,  and  I  placed  him  at  ouce 
in  the  Buffalo  Hospital  of  the  Sisters  of  Charity,  where,  assisted  by 
my  friend.  Prof.  Moore,  of  Rochester,  I  renewed  the  attempts  at  re- 
duction. The  patient  was  placed  under  the  influence  of  chloroform, 
and  during  a  great  portion  of  the  time  occupied  the  pulleys  were 
in  use.  The  elbow  was  pulled  upon,  twisted,  flexed  and  extended 
until  there  seemed  to  be  neither  adhesions,  nor  ligaments,  nor  capsule 
to  prevent  the  reduction.  We  could  move  the  joint  in  every  direction, 
even  laterally,  as  well  as  forwards  and  backwards.  Still  the  bones 
would  not  return  to  their  sockets.  Section  of  the  triceps  seemed  to 
be  the  only  remaining  expedient,  but  the  injury  already  done  to  the 
joint  was  so  great  that  we  did  not  deem  it  prudent  to  prosecute  the 
attempt  any  further.  We  had  occupied  two  hours  in  the  various  pro- 
cedures. Violent  inflammation  supervened,  but  he  was  able  to  return 
home  in  about  two  weeks.  Two  years  after,  I  learned  that  the  arm 
still  remained  unreduced,  and  nearly  anchylosed ;  the  whole  limb  was 
also  much  atrophied  and  very  weak. 

John  Sharkie,  set.  53,  fell  on  the  ith  of  Aug.,  1851.  A  botanic  doctor, 
who  saw  him  on  the  same  day,  and  a  regular  physician,  who  saw  him 
on  the  third  day,  thought  he  had  broken  his  arm.  About  six  weeks 
after  this  he  came  under  the  charge  of  an  almshouse  doctor,  who 


584 


DISLOCATIONS    OF    THE    RADIUS   AND   ULNA. 


Fig.  239. 


"  rebroke"  it,  supposing  it  to  be  a  fracture ;  and  two  months  later  he 
"  broke"  it  again,  but  as  the  arm  was  not  improved  by  these  operations 
he  finally  urged  the  poor  fellow  to  submit  to  amputation  ;  and  it  was 
in  reference  to  this  last  proposition  that  Sharkie  consulted  me,  I  found 
the  radius  and  ulna  dislocated  backwards  and  upwards  one  inch ;  the 
arm  perfectly  straight  and  the  elbow  anchylosed ;  no  pronation  or  supi- 
nation. I  did  not  think  it  prudent  to  make  any  attempt  to  reduce  it, 
but  assured  him  that  if  let  alone  it  would  ultimately  be  quite  useful 
in  many  ways,  and  that  he  should  never  think  of  having  it  cut  off. 

In  three  or  four  instances,  also,  the  accident  has  been  overlooked 
by  the  patient  himself,  or  by  some  empiric,  no  surgeon  having  been 
called  to  see  the  case  until  after  the  lapse  of  several  days  or  weeks. 

In  general,  when  the  reduction  has  been  effected  promptly,  the  pa- 
tients have  recovered  the  complete  use  of  the  elbow-joint  within  a  few 
weeks;  but  many  exceptions  have  from  time  to  time  come  under  my 
notice. 

A  lad  eight  years  old  was  brought  to  me,  whose  arm  had  been  dis- 
located six  months  before,  and  the  reduction  of  which  had  been  accom- 
plished easily  and  promptly  by  Sir  Astley  Cooper's  method.  At  this 
time  the  arm  was  bent  to  a  right  angle,  and  quite  stiff  at  the  elbow- 
joint.  Four  years  later  I  learned  that  the  stiffness  still  continued  in  a 
great  measure,  with  only  slight  improvement. 

Treatment. — Sir  Astley  Cooper  thus 
describes  his  own  method  of  reducing 
this  dislocation  (Fig.  239):  "The  pa- 
tient is  made  to  sit  upon  a  chair,  and 
the  surgeon,  placing  his  knee  on  the 
inner  side  of  the  elbow-joint,  in  the 
bend  of  the  arm,  takes  hold  of  the  pa- 
tient's wrist,  and  bends  the  arm.  At 
the  same  time  he  presses  on  the  radius 
and  ulna  with  his  knee,  so  as  to  sepa- 
rate them  from  the  os  humeri,  and 
thus  the  coronoid  process  is  thrown 
from  the  posterior  fossa  of  the  hume- 
rus; and  whilst  this  pressure  is  sup- 
ported by  the  knee,  the  arm  is  to  be 
forcibly  but  slowly  bent,  and  the  re- 
duction is  soon  effected," 

The  same  practice  has  been  recom- 
mended by  Erichsen,  Gibson,  Samuel 
Cooper,  and  others.  The  plan  recom- 
mended by  Dorsey  is  nearly  identical 
with  that  just  described,  only  that, 
instead  of  the  knee,  he  advises  that 
the  surgeon  "interlock  his  fingers  in 
front  of  the  arm,  just  above  the  elbow, 
and  draw  it  backwards." 
On  the  other  hand.  Listen  and  Miller  recommend,  as  a  better  mode 
of  proceeding,  that  the  patient  shall  be  seated  upon  a  chair,  and  that 


Reduction  ■nritli  the  knee  in  tlie  bend  of  the 
elbow. 


DISLOCATION    OF    EADIUS   AND    ULNA    BACKWARDS,       585 

the  arm  and  forearm  shall  be  pulled  directly  backwards,  so  as  to  relax 
as  completely  as  possible  the  triceps  muscle  while  counter-extension  is 
made  against  the  scapula. 

Skey  says:  "Extension  of  the  forearm  should  be  made  from  the 
hand  or  wrist  in  a  straight  direction  downwards,  as  if  for  the  purpose 
of  simply  elongating  the  arm." 

Pirrie  prefers  that  an  assistant  shall  grasp  the  forearm  near  its 
middle,  instead  of  the  wrist,  and  pull  the  arm  straight  forwards,  while 
at  the  same  moment  the  surgeon  seizes  upon  the  olecranon  process 
with  the  fingers  of  one  hand,  and,  placing  the  palm  of  the  other  against 
the  front  and  upper  part  of  the  forearm-,  pulls  forcibly  backwards,  so 
as  to  draw  out  the  coronoid  process  from  the  olecranon  fossa. 

For  myself,  having  generally  practised  the  method  recommended  by 
Sir  Astley,  and  having  usually  succeeded  in  the  first  attempt  and 
with  the  employment  of  only  moderate  force,  I  confess  that  my  predi- 
lections are  in  its  favor;  yet  I  am  not  entirely  certain  but  that  an  equal 
experience  with  either  of  the  other  modes  recommended  might  have 
changed  these  convictions.  The  truth  is,  I  think,  that  in  recent  cases 
very  little  force  is  generally  requisite  to  accomplish  the  reduction,  and 
that  it  is  not  very  material  which  of  these  several  modes  we  adopt ; 
but  in  case  of  a  failure  by  one  mode,  we  ought  immediately  and  with- 
out hesitation  to  resort  to  another,  as  the  following  case  of  failure  by 
flexion  will  illustrate: — 

A  lad,  aet.  11,  fell  in  a  gymnasium  from  a  height  of  six  feet,  striking 
probably  upon  his  hand.  I  saw  him  within  twenty  minutes,  and  found 
the  arm  in  the  usual  position.  I  attempted  immediately  to  reduce  it  by 
Sir  Astley's  method,  but,  after  a  fair  yet  unsuccessful  trial,  I  extended 
the  forearm  upon  the  arm  until  it  was  nearly  straight,  and  then,  with 
only  moderate  force,  drew  it  promptly  into  place. 

If  we  still  continue  to  encounter  difficulties,  the  patient  ought  at 
once  to  be  placed  under  the  influence  of  an  anaesthetic,  and,  if  neces- 
sary, the  pulleys  should  be  employed. 

When  the  reduction  is  accomplished,  which  is  indicated  generally 
by  the  sudden  slipping  of  the  bones  and  by  the  restoration  of  the 
natural  form  to  the  elbow-joint,  the  surgeon,  in  order  to  confirm  his 
opinion,  must  flex  the  forearm  upon  the  arm  to  a  right  angle.  If  the 
bones  are  in  place,  and  there  is  not  much  swelling,  this  can  generally 
be  done  without  causing  much,  if  any,  pain;  but  if  it  cannot  be  done, 
this  fact  furnishes  presumptive  evidence  that  the  reduction  is  not 
effected.  In  one  instance,  however,  of  recent  luxation,  this  rule  has 
not  held  good.  A  girl,  set.  10,  fell  from  a  tree  upon  her  hand.  I  was 
in  attendance  within  half  an  hour,  and  found  the  usual  signs  charac- 
terizing this  accident.  Eeduction  was  accomplished  readily  by  pulling 
at  the  hand  moderately,  with  the  forearm  flexed,  while  my  left  hand 
pressed  back  the  lower  part  of  the  humerus.  After  the  reduction  it 
was  found  impossible  to  flex  the  arm  to  a  right  angle  without  causing 
severe  pain,  and  it  became  necessary,  after  placing  it  in  a  sling,  to 
allow  the  hand  to  drop  very  low  beside  the  body.  A  good  deal  of 
inflammation  followed ;  but  in  a  few  weeks  the  arm  was  well,  only  that 
for  a  period  of  two  years  or  more  the  elbow  remained  very  tender. 


586  DiSLOCATiojsrs  of  the  radius  and  ulka. 

On  the  other  hand,  an  omission  to  apply  this  rule  has  often  led  the 
surgeon  to  believe  the  reduction  accomplished  when  it  was  not.  Yery 
recently  this  same  thing  has  happened  to  mj^self,  and  as  it  is  the  only 
instance  in  which  I  have  omitted  to  adopt  this  test,  and  the  only  one 
also  in  which  I  have  left  a  bone  unreduced  which  I  believed  to  have 
been  reduced,  it  will  be  proper  to  state  the  case  and  its  results  more 
fully. 

A  lad,  get.  11,  fell  from  a  fence  on  the  22d  of  December,  1858,  and 
dislocated  both  bones  backwards.  I  saw  him  within  two  hours  from 
the  occurrence  of  the  accident.  The  elbow  was  already  considerably 
swollen  and  quite  tender,  but  the  signs  of  dislocation  were  very  mani- 
fest. Seizing  the  wrist  with  one  hand,  and  placing  my  knee  against 
the  front  and  lower  part  of  the  humerus,  I  pulled  steadily  for  some 
time,  and  with  much  more  force  than  is  usually  necessary,  until  at 
length  two  distinct  and  successive  snaps  were  felt,  such  as  one  often 
feels  when  the  two  bones  resume  their  sockets.  Kelinquishing  my 
grasp,  it  was  observed  by  myself  and  the  parents  that  the  deformity 
had  disappeared-.  The  reduction  seemed  to  be  complete,  and  so  I 
announced.  I  then  requested  the  lad  to  permit  me  to  bend  the  elbow, 
and  place  it  in  a  sling,  but  this  he  peremptorily  refused  to  do,  and  ran 
away  from  me,  nor  would  any  arguments  or  entreaties  persuade  him 
to  allow  me  again  to  touch  it.  I  reassured  the  parents  and  child,  how- 
ever, that  all  was  right,  and  left  the  house.  During  several  successive 
days  I  saw  the  little  patient,  but  although  the  arm  remained  swollen 
and  very  tender,  I  did  not  suspect  the  cause  until  the  ninth  day ;  and 
on  the  tenth  day,  having  placed  him  under  the  influence  of  chloroform, 
the  reduction  was  easily  and  satisfactorily  accomplished.  The  recovery 
has  been  slow.  At  the  end  of  six  weeks  I  found  the  motions  of  the 
elbow-joint  not  completely  restored,  and  the  forefinger  was  partially 
paralyzed;  but  from  this  condition  it  has  gradually  recovered,  and 
two  months  later  the  functions  of  the  arm  and  hand  were  completely 
restored. 

The  mistake  in  this  instance  was  the  more  mortifying  because  I  had 
just  seen  a  case  in  a  lad  only  a  little  older,  in  which  another  surgeon 
had  committed  the  same  error,  and  after  the  lapse  of  twelve  or  fourteen 
days  I  had  myself  made  the  reduction ;  and  I  was  fully  awake,  there- 
fore, to  the  possibility  of  the  mistake. 

The  circumstance  of  the  diminution  and  apparent  disappearance  of 
the  deformity,  and  the  sensation  of  a  double  click,  can  only  be  explained 
by  assuming  that  originally  the  coronoid  process  was  resting  in  the 
olecranon  fossa,  and  that  by  manipulation  the  bones  had  been  removed 
nearer  their  sockets,  yet  not  actually  reduced.  The  swelling,  also, 
rendered  more  difficult  a  diagnosis  which,  now,  nothing  but  the  flexion 
of  the  forearm  could  have  determined  positively. 

If  much  time  has  elapsed  since  the  occurrence  of  the  dislocation  the 
reduction  is  accomplished  with  difficulty,  if,  indeed,  it  can  be  reduced 
at  all.  There  are  many  cases  upon  record,  however,  in  which  surgeons 
have  been  successful  after  the  lapse  of  many  weeks,  or  even  months. 
Boyer  thought  it  was  not  possible  to  effect  the  reduction  after  four  or 


DISLOCATION    OF    EADIUS    AND    ULNA    BACKWAEDS.        587 

six  weeks ;  but  Capelletti,  of  Trieste,  succeeded  after  seventy  days  ;^ 
Sir  Astley  Cooper  at  three  months  ;^  Malgaigne  after  three  months  and 
twenty-one  days.^  Eoux  succeeded  in  the  case  of  a  young  man,  twenty- 
two  years  of  age,  whose  elbow  had  been  dislocated  five  months.'' 
Blackman,  of  Cincinnati,  informs  me  that  he  has  reduced  a  lateral  luxa- 
tion after  five  months.  Brainard,  of  Chicago,  reduced  a  dislocated 
elbow  in  a  boy  of  nineteen  years,  after  five  months  and  thirteen  days. 
In  this  case  the  surgeon  who  had  first  seen  the  patient  supposed  that 
he  had  reduced  the  dislocation.^  Gorre,  Gerdy,  and  Drake,  succeeded  in 
four  cases  after  six  months;^  and  finally.  Starch  claims  to  have  been 
successful  after  two  years  and  one  month. ^  To  which  enumeration 
Denuce  has  added  seventeen  other  examples,  said  to  have  been  reduced 
at  various  periods,  ranging  from  one  month  to  one  hundred  and  four- 
teen days.^ 

Nevertheless  the  fact  is  in  the  main  as  stated  by  Boyer ;  and  if  so 
many  cases  can  be  found  in  which  surgeons  have  succeeded  at  a  later 
period,  they  are  not  probably  in  the  proportion  of  one  to  ten  as  com- 
pared with  the  failures;  but  the  failures  have  not  received  the  same 
publicity.  Nor  indeed  have  all  the  severe  accidents,  such  as  violent 
inflammation,  suppuration,  gangrene,  and  even  death,  been  faithfully 
declared.  Denuce  says  he  has  been  able  to  trace  out  five  or  six  ex- 
amples in  which,  although  the  arm  was  reduced,  grave  accidents 
resulted,  and  Yelpeau's  patient  actually  died  in  consequence. 

Dixi  Crosby,  of  New  Hampshire,  has  treated  two  cases  of  ancient  dis- 
location of  the  forearm  backwards,  by  bending  the  elbow  forcibly  so  as 
to  break  the  olecranon  process,  after  which  the  reduction  was  easily 
accomplished  by  extension.  R.  D.  Mussey,  of  Cincinnati,  has  suc- 
ceeded once  in  the  same  manner.  In  all  these  examples  the  elbow 
was  restored  to  a  very  useful  amount  of  motion.^ 

The  dislocation  being  reduced,  it  may  be  a  matter  of  prudence  some- 
times to  apply  a  right-angled  splint,  first  carefully  padded,  to  the 
palmar  surface  of  the  arm  and  forearm ;  remembering,  however,  that 
considerable  swelling  will  soon  occur,  and  that  it  ought  not  therefore  to 
be  bandaged  to  the  limb  very  tightly.  At  least  once  a  day  it  should 
be  removed,  and  the  arm  examined ;  and  in  very  few  cases  can  it  be 
necessary  or  judicious  to  continue  its  application  beyond  one  week. 
At  the  same  time  if  there  is  any  especial  tendency  in  the  radius  to 
become  displaced  backwards,  owing  to  a  rupture  of  its  annular  liga- 
ment, this  must  be  prevented,  if  possible,  by  a  compress  and  bandage. 
Some  surgeons  regard  these  precautions  as  necessary  in  all  cases,  but 
I  have  seldom  employed  any  splint  or  bandage  whatever,  nor  have  I 
ever  had  reason  to  regret  this  omission. 

Finally,  we  are  to  place  the  arm  in  a  sling,  and  adopt  such  measures 

'  Cappelletti,  Am.  Journ.  Med.,  vol.  xix.,  from  Annal.  Univ.  de  Med.  for  Oct.  1835. 

2  Sir  Astley  Cooper,  On  Dislocations  and  Fractures,  Amer.  ed.,  p.  388. 

3  Malgaigne,  Am.  .Journ.  Med.  Sci.,  vol.  xxiii.  p.  238,  from  Revue  Med.,  Dec.  1837. 
*  Roux,  Amer.  Journ.  Med.  Sci.,  vol.  xvi.  p.  526,  from  Archives  Gen  ,  Dec.  1834. 

5  Brainard,  Illinois  and  Indiana  Med.  Journ.,  1847. 

8  Memoire  sur  les  luxations  du  coude,  par  Paul  Denuce,  Paris,  1854,  pp.  86,  87. 
'  Denuce,  op.  cit.,  p.  87.  ^  Op-  cit. 

P  Crosby,  Mussey,  Trans.  Amer.  Med.  Assoc,  vol.  iii.  p.  357. 


588 


DISLOCATIONS    OF    THE    RADIUS    AND    ULKA. 


as  are  calculated  at  first  to  reduce  the  inflammation ;  and  at  a  very- 
early  day  we  ought  to  begin  to  move  the  elbow-joint,  in  order  to  pre- 
vent anchylosis. 


.Fig.  240. 


§  2.  Dislocation  of  the  Radius  and  Ulna  Outwards  (to  the  Radial 

Side.) 

The  large  majority  of  outward  dislocations  of  the  forearm  are 
incomplete ;  indeed,  only  nine  examples  of  a  complete  dislocation  have 
been  collected  by  Denuce  including  two  seen  by  himself,  Malgaigne 
has  since  added  two  more,  making  in  all  eleven  cases.  All  these 
examples  have  occurred  in  the  practice  of  French  surgeons.  So  far 
as  I  am  able  to  discover,  no  American  or  English  surgeon  has  ever 
reported  a  single  example. 

Incomplete  dislocations  must  therefore  in  this  case  be  regarded  as 
typical ;  but  even  these  are  by  no  means  frequent. 

Causes. — A  careful  examination  of  a  large  number  of  recorded  ex- 
amples, and  of  those  which  have  come  under  my  own  eye,  renders  it  cer- 
tain that  a  majority  of  these  accidents  result  from  a  blow  received 
directly  upon  the  inner  side  of  the  forearm  or  upon  the  outer  side  of  the 
humerus,  or  from  the  action  of  two  forces  pressing  in  an  opposite  direc- 
tion. Of  course  these  forces  must  act  upon  the 
bones  somewhere  in  the  neighborhood  of  the  elbow- 
joint.  Occasionally  it  has  been  produced  by  a  fall 
upon  the  hand ;  sometimes  by  a  violent  twist  of  the 
arm,  as  when  the  hand  is  caught  in  machinery ; 
and  in  other  cases  it  has  been  found  consecutive 
upon  a  dislocation  backwards,  being  produced  in 
the  attempts  made  to  accomplish  reduction  of  this 
latter  form  of  dislocation. 

Pathology. — In  most  of  the  examples  of  simple, 
incomplete  outward  luxation  of  the  forearm,  the 
great  sigmoid  cavity  of  the  ulna  still  embraces  the 
lower  end  of  the  humerus,  but  instead  of  reposing 
upon  the  trochlea,  it  is  carried  outwards  half  an 
inch  or  more  so  as  to  rest  its  central  crest  upon 
the  depression  which  separates  the  condyle  from 
the  trochlea.  (Fig.  240.)  If  the  annular  ligament 
remains  unbroken  the  radius  is  displaced  in  the 
same  direction  and  to  the  same  extent,  its  head 
resting  against  and  directly  below  the  epicondyle. 
Occasionally,  however,  where  the  violence  has 
been  greater,  the  central  crest  of  the  great  sigmoid 
cavity  rests  fairly  upon  the  condyle,  or  upon  the 
articulating  surface  of  the  humerus  where  the  head 
of  the  radius  was  formerly  applied,  and  the  dislo- 
cation approaches  more  nearly  to  the  character  of 
a  complete  luxation.  At  the  same  time,  owing  perhaps  to  the  resist- 
ance afforded  'by  the  skin,  or  some  of  the  ligaments,  the  head  of  the 


Most  frequent  form  of 
incomplete  outward  dislo- 
cation of  tlie  forearm. 


DISLOCATION    OF    RADIUS    AND    ULNA    OUTWARDS.         589 

radius  may  be  thrown  either  forwards  or  backwards  so  as  to  be  out 
of  line  with  the  ulna.  Such  a  displacement  generally  implies  a  rup- 
ture of  the  annular  ligament. 

We  have  now  only  to  suppose  the  action  of  a  more  considerable 
force  in  the  same  direction  to  render  the  dislocation  complete;  in 
which  case  the  upper  end  of  the  radius  is  sometimes  thrown  com- 
pletely forwards,  and  its  head  may  even  be  found  resting  in  front  of 
the  ulna,  occasioning  an  extreme  pronation  of  the  forearm  and  hand. 

The  anconeus  and  brachialis  anticus  are  the  only  muscles  in  either 
of  these  dislocations  whose  fibres  are  generally  much  disturbed ;  the 
biceps  and  triceps  being  only  made  to  traverse  the  articulation  a  little 
more  obliquely. 

Denuce,  Malgaigne,  A.  Cooper,  and  others  have  preferred  to  speak 
of  the  dislocation  backwards  and  outwards  as  a  distinct  form  or  species 
of  dislocation.  I  prefer  to  regard  it  as  only  a  variety  of  the  outward 
luxation,  since  it  may,  and  no  doubt  often  does,  occur  consecutively 
upon  a  simple  incomplete  outward  dislocation;  and  if  the  dislocation 
outward  is  complete,  the  bones  of  the  forearm  can  scarcely  fail  to  be 
drawn  more  or  less  upwards.  Sometimes  also  it  has  been  consecutive 
upon  a  simple  backward  dislocation,  or  upon  unsuccessful  attempts  at 
reduction  where  the  form  of  dislocation  was  originally  backwards; 
yet  as  it  does  not  so  naturally  follow  upon  a  complete  backward  dis- 
location as  upon  a  complete  outward  luxation,  I  find  sufficient  reason 
for  studying  its  mechanism  in  this  place. 

The  beak  of  the  olecranon  process  not  only,  but  a  large  portion  of 
the  body  of  this  process  now  lies  above  and  behind  the  condyle;  the 
brachialis  anticus  becomes  more  stretched  if  not  actually  torn,  and  the 
biceps  is  laid  against  the  articulating  surface  of  the  humerus  ;  but  the 
triceps  becomes  again  relaxed,  as  in  simple  dislocation  backwards  and 
upwards. 

In  all  these  dislocations  the  capsular  ligaments  are  more  or  less 
extensively  torn,  but  the  principal  arteries  and  nerves  do  not  generally 
suffer  greatly  if  at  all. 

Sympioms. — The  forearm  is  usually  flexed  to  about  the  same  angle 
at  which  we  have  found  it  in  dislocations  backwards,  sometimes  it  is 
demi-flexed,  and  it  is  also  forcibly  pronated.  The  elbow-joint  is 
immovable.  The  most  striking  diagnostic  sign,  however,  consists  in 
the  unnatural  form  of  the  elbow-joint,  which  is  so  remarkable  as  not 
to  be  easily  misunderstood.  The  internal  condyle  of  the  humerus 
(epitrochlea)  projects  strongly  to  the  inner  side,  leaving  a  deep  depres- 
sion below  ;  while  upon  the  outer  side  the  head  of  the  radius,  with  its 
cup-like  extremity,  can  be  distinctly  felt,  and  made  to  rotate  outside 
of  its  socket.  The  olecranon  process,  driven  from  its  fossa,  projects 
more  or  less  posteriorly,  and  even  the  fossa  itself  may  sometimes  be 
plainly  felt. 

A  girl,  twelve  years  old,  had  fallen  upon  the  inside  of  her  elbow, 
producing  a  dislocation  outwards  of  the  forearm.  I  saw  her  within 
half  an  hour.  The  forearm  was  bent  upon  the  arm  about  fifteen  de- 
grees, and  immovably  fixed.     The  head  of  the  radius  could  be  dis- 


590  DISLOCATIONS    OF    THE    RADIUS   AND   ULNA. 

tinctly  felt  external  to,  and  a  little  in  front  of  the  outer  condyle,  while 
the  olecranon  process  of  the  ulna,  which  rested  upon  the  back  and 
outer  surface  of  the  humerus,  was  less  distinctly  felt  than  in  the  oppo- 
site arm.  The  inner  condyle  projected  sharply  to  the  inside,  and  the 
olecranon  fossa  was  plainly  felt  with  the  fingers.  The  child  was  suffer- 
ing very  little  pain. 

Seizing  the  wrist  with  my  right  hand  and  the  lower  end  of  the 
humerus  with  the  left,  and  making  moderate  extension  in  these  oppo- 
site directions,  the  bones  easily,  and  after  only  a  moment's  effort,  re- 
sumed their  places.     Her  recovery  was  rapid  and  complete. 

If  the  dislocation  is  complete  the  position  of  the  arm  is  usually  the 
same,  but  the  pronation  of  the  hand  is  greater,  and  the  projection  of 
the  inner  condyle  more  striking. 

If  now  the  bones  by  a  continuance  of  the  original  force,  or.  by  the 
action  of  the  triceps,  are  drawn  upwards  also,  the  arm  becomes  a  little 
more  flexed,  and  the  olecranon  process  more  prominent,  while  the 
length  of  the  whole  limb  is  sensibly  diminished. 

Prognosis. — In  recent  cases  of  incomplete  outward  luxation,  and 
where  no  complications  exist,  the  reduction  is  generally  easily  effected  ; 
and  M.  Thierry  claims  to  have  reduced  an  outward  and  backward 
luxation  after  eight  months.  A  patient  of  whom  Debruyn  has  spoken 
was  not  so  fortunate.  On  the  16th  of  April,  1841,  a  lad,  set.  18,  fell 
upon  the  palm  of  his  hand  and  dislocated  both  bones  outwards  and 
backwards  ;  on  the  following  morning  a  surgeon  attempted  to  reduce 
the  dislocation,  and  the  attempt  was  repeated  on  the  next  day  by  an- 
other surgeon ;  but  on  the  day  following  this  last  attempt,  gangrene 
ensued  in  consequence  of  the  great  violence  employed  by  the  surgeons, 
and  although  the  limb  was  amputated  the  patient  died.  The  autopsy 
showed  that  both  the  brachial  artery  and  the  median  nerve  were  torn 
asunder,  and  that  the  tendons  of  the  biceps  and  brachialis  anticus 
were  slipped  behind  the  outer  condyle,  probably  having  been  thrown 
into  this  position  during  the  violent  twistings  to  which  the  arm  had 
been  subjected.* 

I  have  seen  three  examples  of  dislocation  upwards  and  outwards 
which  the  medical  attendants  had  failed  to  reduce.  The  first  was  in 
the  case  of  a  lad,  Wm.  Kinkaid,  fourteen  years  old,  who  had  fallen 
from  a  wagon  and  struck  upon  the  palm  of  his  left  hand.  The  sur- 
geon who  was  immediately  called  made  extension,  and  supposed  that 
the  reduction  was  accomplished.  The  lad  was  brought  to  me  a  few 
months  after  the  accident.  The  arm  was  slightly  flexed,  and  neither 
prone  nor  supine.  There  existed  only  a  slight  motion  at  the  elbow- 
joint.  I  did  not  think  it  worth  while  to  make  any  attempt  at  reduc- 
tion. Several  years  after  this,  in  the  month  of  February,  1859,  I  had 
an  opportunity  of  examining  the  arm  again.  He  had  now  recovered 
considerable  motion  in  the  joint,  but  he  could  not  tie  his  cravat. 
Pronation  and  supination  were  perfect. 

In  the  second  example,  a  lady,  set.  33,  had  fallen  upon  the  inside  of 
her  elbow,  and  reduction  not  having  been  accomplished,  I  found  her, 

'  Denuce,  op.  cit.,  p.  103. 


DISLOCATIOISr    OF    EADIUS    AND    ULNA    OUTWAKDS.        591 

nine  weeks  after  the  accident,  with  scarcely  any  motion  at  the  elbow- 
joint,  and  complaining  of  a  numbness  in  the  forearm  and  hand. 

The  third  instance  of  unreduced  dislocation  I  will  relate  more  at 
length. 

Francis  Banfield,  aged  twenty-two  years,  a  resident  of  Alleghany 
County,  IST.  Y.,  on  the  31st  of  September,  1857,  fell  from  the  sweep  of  a 
threshing  machine  to  the  ground,  a  distance  of  about  five  feet,  striking 
upon  the  palm  of  his  hand,  his  arm  being  extended  in  front  of  him.  On 
rising  he  found  his  arm  forcibly  flexed  and  abducted.  He  straight- 
ened it  without  difficulty,  and  it  assumed  the  position  it  now  occupies. 
A  physician  was  called  and  saw  the  patient  an  hour  and  a  half  after 
the  accident,  who  pronounced  it  a  case  of  dislocation  of  the  radius  and 
ulna,  and  made  efforts  at  reduction,  which  he  continued  from  S|  A.M. 
until  2  P.  M.,  a  period  of  five  and  a  half  hours,  to  no  purpose,  when 
he  abandoned  the  attempt.  During  the  attempt  at  reduction,  the  ex- 
tension was  made  at  times  with  the  arm  flexed,  and  at  others  extended. 
At  9  P.  M.,  another  physician  was  called,  who  made  efforts  at  reduc- 
tion until  3  A.  M.,  upwards  of  six  hours,  at  which  time  he  also  aban- 
doned the  attempt.  On  the  third  day  another  physician,  the  patient 
being  under  the  influence  of  ether,  made  efforts  at  reduction  for 
twenty  minutes,  when  he  pronounced  it  in  place,  and  applied  a  bandage. 
From  the  patient's  account  the  arm  was  swollen  to  such  an  extent  as 
to  render  this  point  difficult  to  determine.  On  the  fifth  day  the  first 
physician  was  called,  and  believing  that  he  discovered  a  grating,  pro- 
nounced it  a  fracture  of  the  external  condyle. 

Four  months  after  the  accident,  when  the  patient  applied  to  me,  the 
limb  presented  the  following  appearances:  "The  forearm  extended 
upon  the  arm ;  looking  at  the  limb  along  its  radial  margin  we  notice 
a  gentle  outward  inclination  of  the  forearm  from  the  elbow  down,  but 
by  manipulation  this  may  be  greatly  increased ;  the  power  of  prona- 
tion and  supination  is  not  affected ;  the  inner  condyle  projects  an 
inch  to  the  ulnar  side  ;  the  head  of  the  radius,  completely  removed 
from  its  socket,  projects  to  an  equal  extent  on  the  radial  side.  The 
top  of  the  olcranon  process  is  an  inch  higher  than  the  top  of  the  inner 
condyle,  so  that  the  radius  and  ulna  are  carried  upwards  as  well  as 
outwards." 

I  believe  that  the  external  condyle  was  not  broken,  as  in  that  case, 
the  arm  would  be  permanently  deflected  outwards  to  a  much  greater 
extent.  For  although  this  arm  may  be  deflected  outwards  by  the 
surgeon  to  an  angle  of  135°,  still  the  degree  of  mobility  which  exists 
would  be  adverse  to  the  supposition  of  its  being  a  fracture  of  the  ex- 
ternal condyle.  The  condyles  also  can  be  plainly  felt  in  their  natural 
situations,  which  would  not  be  the  case,  if  a  fracture  of  the  external 
condyle  existed.  The  patient  was  advised  not  to  submit  to  any  fur- 
ther attempts  at  reduction. 

Treatment. — In  relation  to  the  treatment  of  these  accidents  we  have 
little  to  add  to  what  has  already  been  said  of  the  treatment  of  dislo- 
cations backwards.  The  reduction,  if  effected  at  all,  has  generally 
been  accomplished  by  moderate  extension,  or  by  extension  combined 
with  lateral  pressure.     If  the  head  of  the  radius  is  in  front  of  the 


592 


DISLOCATIONS    OF    THE    RADIUS    AND    ULNA. 


humerus,  or  of  the  ulna,  the  hand  should  be  first  supined,  and  then 
the  extension  should  be  applied.  In  some  cases  the  reduction  has 
been  effected  by  placing  the  knee  in  the  bend  of  the  elbow  and  flexing 
the  forearm,  while  the  surgeon  was  making  extension  from  the  hand. 


§  3.  Dislocation  op  the  Radius  and  Ulna  Inwards  (to  the  Ulnar  Side). 

This  form  of  dislocation  is  much  more  rare  than  the  dislocation 
outwards,  a  fact  which  may  perhaps  find  a  sufficient  explanation  in  the  \ 
peculiar  form  of  the  trochlea,  the  inner  half  of  which  rises  much  higher 
than  the  outer,  forming  thus  an  elevated  inclined  plane,  over  which  : 
the  articulating  surface  of  the  ulna  must  rise  before  the  dislocation  i 
can  occur. 

Like  the  opposite  dislocation,  the  typical  form  of  the  accident  is  j 
that  in  which  the  displacement  is  incomplete ;  indeed,  no  example  of  \ 
a  complete  inward  dislocation  has,  we  think,  been  yet  recorded. 

Causes. — A  fall  upon  the  hand  or  forearm,  a  blow  upon  the  radial  , 
side  of  the  forearm  near  its  upper  end,  or  upon  the  ulnar  side  of  the 
arm,  near  its  lower  end,  a  violent  wrenching  of  the  limb,  are  among  ; 
the  causes  which  may  occasion  this  dislocation. 

Pathology. — The  ridge  which  divides  antero-posteriorly  the  greater 
sigmoid  cavity  of  the  ulna,  having  been  driven  over  the  elevated  inner 
margin  of  the  trochlea,  falls  down  upon  the  epi troch- 
lea, so  as,  in  some  sense,  to  embrace  it  instead  of  the 
trochlea;  while  the  head  of  the  radius  passes  inwards 
also,  and  is  made  to  occupy  the  trochlea,  from  which 
the  ulna  has  escaped.  Generally  the  head  of  the  radius 
is  found  in  the  same  line  with  the  ulna  (Fig.  241),  but 
it  may  suffer  a  subluxation  and  be  found  a  little  in 
advance  of  the  ulna,  or  possibly  a  little  in  the  rear. 
I  choose  also  to  regard  the  dislocation  inwards 
and  upwards  as  only  a  variety  of  the  dislocation 
inwards;  in  which  form  of  the  accident  the  coro- 
noid  process  of  the  ulna  is  thrust  upwards  above  the 
epicondyle,  and  the  head  of  the  radius  occupies  the 
olecranon  fossa,  or  rests  upon  the  back  of  the 
humerus  somewhere  in  this  vicinity. 

In  addition  to  the  injury  suffered  by  the  liga- 
ments and  muscles,  the  ulnar  nerve  in  both  varie- 
ties of  inward  dislocation  is  peculiarly  liable  to  con- 
tusion, in  consequence  of  its  being  crushed  between 
the  olecranon  process  and  the  epitrochlea. 

Symptoms. — If  the  dislocation  is  only  inwards,  the 
olecranon  process  can  be  felt  projecting  upon  the 
inner  side,  and  completely  concealing  the  epicon- 
dyle ;  while  the  head  of  the  radius,  having  aban- 
doned its  socket,  may  be  felt  indistinctly  in  the  bend 
of  the  arm.  The  external  condyle  (epicondyle)  is 
remarkably  prominent.     The  forearm  is  generally  more  or  less  flexed, 


Fig.  241. 


Most  frequent  form  of 
incomplete  inward  dislo- 
cation of  the  forearm. 


p 


DISLOCATION"    OF    RADIUS    AND    ULNA    INWARDS.  593 


and  the  hand  forcibly  pronated.  The  natural  outward  deflection  of  the 
forearm  is  also  lost,  or  it  may  be  even  inclined  slightly  inwards.  This 
phenomenon  is  explained  by  the  position  of  the  epicondyle,  upon 
which  the  greater  sigmoid  cavity  now  rests,  allowing  the  ulna  to  over- 
lap a  little  upon  the  humerus ;  rendering  the  forearm  actually  some- 
what shorter  along  its  ulnar  margin,  although  the  head  of  the  radius 
may  still  occupy  the  summit  of  the  trochlea. 

If  the  bones  are  displaced  upwards  as  well  as  inwards,  a  consider- 
able shortening  is  declared,  and  the  head  of  the  radius  may  now  be 
felt  behind  the  trochlea,  or  over  the  olecranon  fossa.  In  three  of  the 
four  examples  seen  by  Malgaigne,  all  of  them  ancient,  the  forearm 
was  in  a  state  of  supination.  Other  surgeons  have  met  with  cases  in 
which  the  forearm  was  supine,  but  they  must  be  considered  as  excep- 
tions to  the  rule. 

Prognosis. — Malgaigne  was  unable  to  reduce  the  dislocation  in  a 
recent  case  of  incomplete  internal  dislocation,  which  came  under  his 
own  notice.  Triquet  succeeded  in  a  child  seven  years  old,  on  the 
fifteenth  day,  after  many  trials;  but  the  movements  of  the  elbow-joint 
were  never  restored.  Debruyn  succeeded  on  the  fifth  day,  but  not 
without  diflBculty ;  and  in  the  only  remaining  example  which  has 
been  put  upon  record,  the  precise  character  of  the  accident  having 
been  determined  by  Velpeau,  reduction  was  easily  accomplished,  and 
on  the  eighth  day  the  patient  was  dismissed.^ 

Of  the  four  examples  of  inward  and  backward  luxation  seen  by 
Malgaigne,  not  one  was  ever  reduced;  but  as  the  history  of  them  all 
is  not  complete,  it  is  by  no  means  to  be  inferred  that  reduction  could 
not  have  been  easily  accomplished,  at  least  in  some  of  them,  at  the 
first.  Nor,  with  such  imperfect  details  before  us,  can  we  understand 
fully  what  complications  may  have  existed,  such  as  would  perhaps 
render  these  exceptional,  rather  than  illustrative  examples. 

One  of  these  patients  had  a  completely  anchylosed  elbow  at  the  end 
of  two  years,  but  pronation  and  supination  were  preserved.  In  the 
case  of  another,  however,  even  flexion  and  extension  were  as  perfect 
as  in  the  normal  condition. 

Treatment. — The  indications  of  treatment  are  the  same  as  in  disloca- 
tions outwards,  with  only  such  slight  modifications  as  the  judgment 
of  every  surgeon  must  naturally  suggest.  I  prefer  to  employ  by  way 
of  illustration  the  example  diagnosticated  by  Yelpeau. 

On  the  10th  of  May,  184:8,  Alexandrine  Guyot,  set.  22,  entered  the 
Hospital  of  La  Charite,  with  an  incomplete  inward  dislocation  of  the 
forearm  which  had  just  occurred.  The  hand  and  forearm  were  in  a 
state  of  forced  pronation,  half-flexed,  and  the  whole  limb  from  the 
elbow  downwards  was  deflected  inwards.  There  were  present  also  all 
the  other  usual  signs  of  this  dislocation,  and  Velpeau  had  no  doubt  as 
to  its  true  character. 

In  order  to  accomplish  reduction,  one  assistant  made  counter-exten- 
sion upon  the  arm,  while  a  second  made  direct  extension  upon  the 
forearm.     At  first  the  tractions  were  made  in  the  direction  of  the  fore- 

'  Deuuce,  op.  cit.,  pp.  154-156. 

38 


594  DISLOCATIONS    OF    THE    EADIUS   AND    ULNA. 

arm  (flexed  and  prone),  but  gradually  the  arm  was  straightened  and 
supinated.  Then  the  surgeon,  seizing  with  one  hand  the  superior  ex- 
tremity of  the  forearm,  and  with  the  other  the  inferior  extremity  of 
the  arm,  acted  forcibly  upon  the  two  portions  in  opposite  directions, 
and  immediately  the  reduction  was  effected  with  a  noise.^ 


§  4.  Dislocation  op  the  Kadius  and  Ulna  Forwards. 

Sir  Astley  Cooper,  Yidal  (de  Cassis),  and  others  have  denied  that  this 
dislocation  was  possible  without  a  fracture  of  the  olecranon  process ; 
but  Monin,  Prior,  Yelpeau,  and  Denucd  have  each  reported  one  ex- 
ample, so  that  its  existence  may  now  be  considered  as  established. 
Nevertheless,  it  is  only  as  a  result  of  very  violent  and  extraordinary 
accidents,  by  which  the  forearm  is  forcibly  flexed,  or  greatly  ex- 
tended, or  twisted,  or  in  some  other  unusual  and  indirect  way  the 
olecranon  is  placed  in  front  of  the  humerus. 

The  following  is  a  summary  of  the  facts  in  Yelpeau's  case.  Alex- 
andrine Carelli,  set.  23,  was  knocked  down  by  a  carriage,  on  the  first 
of  July,  1848,  the  wheel  passing  over  the  right  arm.  The  arm  was 
found  in  a  right-angled  position,  and  it  could  neither  be  flexed  nor 
extended;  the  forearm  was  strongly  supinated;  the  projecting  angle 
usually  made  by  the  olecranon  process  was  replaced  by  the  irregular 
extremity  of  the  humerus ;  the  forearm  was  shortened  upon  the  arm  ; 
the  head  of  the  radius  resting  in  the  coronoid  fossa,  and  the  olecranon 
process  being  also  carried  upwards,  and  a  little  outwards.  Eeduction 
was  easily  accomplished,  and  the  patient  left  on  the  nineteenth  day, 
with  only  a  slight  remaining  stifi'ness  in  the  joint.^ 

Chapel  has  reported  a  case  of  dislocation  forwards  and  outwards 
which  he  readily  reduced  soon  after  it  occurred ,  while  Colson,  Leva 
and  Guyot  have  each  reported  one  example  of  sub-]uxa,t\on  forwards, 
in  which  the  extremity  of  the  olecranon  process  has  been  found  rest- 
ing upon  the  extremity  of  the  humeral  trochlea.^ 

Treatment. — If  the  dislocation  is  complete  and  the  forearm  is  short- 
ened and  flexed  upon  the  arm,  the  reduction  should  be  first  attempted 
by  violent  flexion,  or  by  flexion  combined  with  extension  from  the 
wrist  and  counter-extension  from  the  lower  portion  of  the  humerus. 
If  the  dislocation  is  incomplete,  and  the  forearm  is  extended  upon  the 
arm,  the  reduction  may  be  readily  accomplished  by  extension  alone, 
or  by  moderate  flexion. 

1  Denuce,  op.  cit.,  p.  155.  2  i^i^,^  p_  uq.  ^  ibj^.^  p.  12O. 


DISLOCATIONS    OF    THE    WEIST.  595 


CHAPTER    X. 

DISLOCATIONS   OF   THE  TVEIST    (EADIO-C ARPAL 
ARTICULATIOX). 

Regarded  as  an  accident  of  not  unusual  occurrence  by  Hippo- 
crates, J.  L,  Petit,  Duvernev,  Boyer,  and  by  most  if  not  all  the 
older  writers,  its  frequency  began  to  be  questioned  by  Pouteau,  and 
finally  its  existence  was  almost  absolutely  denied  by  Dupuytren, 
who  remarks:  "I  have  for  a  long  time  publicly  taught  that  fractures 
of  the  carpal  end  of  the  radius  are  extremely  common ;  that  I  had 
always  found  these  supposed  dislocations  of  the  wrist  turn  out  to  be 
fractures ;  and  that  in  spite  of  all  which  has  been  said  upon  the  subject, 
I  have  never  met  with,  or  heard  of,  one  single  well  authenticated  and 
convincing  case  of  the  dislocation  in  question."  Dupuytren  subse- 
quently declared  that  he  would  not  positively  deny  the  possibility  of 
the  accident,  yet  that  "it  must  at  least  be  admitted  that  the  accident  is 
an  extremely  rare  one."  Wishing  to  explain  this  infrequency,  he  says : 
"In  examining  the  structure  of  the  soft  parts,  one  cannot  fail  to  per- 
ceive that  it  is  not  the  ligaments  which  prevent  the  displacement  of 
the  articular  surface  forwards,  but  that  this  effect  is  especially  due  to 
the  multitude  of  flexor  tendons,  deprived  as  they  are  at  this  point  of 
all  the  fleshy  parts,  and  reduced  to  the  simple  fibrous  tissue  which 
composes  them.  These  tendons  are  bound  together  beneath  the  ante- 
rior annular  ligament  of  the  wrist;  and  thus  offer  so  efficient  a  resist- 
ance that  severe  falls  are  insufficient  to  tear  them  through;  the  hand 
is  forced  into  a  state  of  extreme  tension,  and  the  tendons  are  firmly 
applied  on  the  anterior  part  of  the  radio-carpal  articulation.  If  the 
extension  is  still  further  augmented,  the  wrist-joint  is  yet  more  closely 
clasped  by  these  parts,  and  their  power  of  resistance  is  incalculable ;  I 
am  convinced  that  a  force  equivalent  to  one  thousand  pounds  weight 
would  be  inadequate  to  overcome  it;  and  the  known  power  of  the 
tendo  Achillis  is  sufficient  to  prove  that  this  computation  is  not  ex- 
aggerated, 

"The  risk  of  dislocation  backwards  by  a  fall  on  the  dorsal  surface 
of  the  hand  is  equally  precluded  by  the  tendons  of  the  extensor  mus- 
cles. Their  arrangement  and  relations  at  the  back  of  the  joint  are  simi- 
lar; it  is  true  they  are  not  quite  so  strong;  but  we  must  admit  that 
their  power  of  resistance  is  very  considerable,  when  we  take  into  con- 
sideration how  they  are  inclosed  in  sheaths  as  they  cross  beneath  the 
posterior  annular  ligament  of  the  wrist.  I  have  not  alluded  to  the 
ulna,  for  it  has  really  little  or  nothing  to  do  with  these  movements,  as 
it  does  not  articulate  (directly)  with  the  hand. 

"To  sum  up,  then,  the  extreme  rarity  of  dislocation  forwards  or 


596  DISLOCATIONS    OF    THE    WEIST. 

backwards  is  owing  to  the  obstacles  opposed  by  the  flexor  and  exten- 
sor tendons," 

The  opinion  of  such  a  writer  as  Dupuytren,  whose  experience  was 
very  great,  and  who  described  only  what  he  had  seen,  is  always  en- 
titled to  profound  respect ;  yet  it  has  been  the  practice  of  nearly  all 
who  have  made  any  reference  to  his  opinions  in  this  matter  to  speak 
of  them  lightly,  and  not  a  few  have  falsely  represented  him  as  saying 
that  such  a  dislocation  was  "  impossible."  The  fact  is,  that  surgeons 
do  still  constantly  mistake  fractures  of  the  lower  end  of  the  radius  for 
dislocations,  as  my  own  personal  observation  can  attest;  and  notwith- 
standing examples  have  been  reported  by  Een6,  Marjolin,  Padieu, 
Cruveilhier,  Voillemier,  Boinet,  Malgaigne,Scoutetten,  Bransby  Cooper, 
Fergusson,  W.  Parker,  and  others,  yet  the  whole  number  of  cases  for 
which  the  distinction  is  claimed  is,  to  this  day,  so  inconsiderable  as 
only  to  establish  the  value  and  accuracy  of  Dupuytren's  opinion  that 
the  "accident  is  an  extremely  rare  one."  But  it  is,  perhaps,  most 
remarkable  that  while  very  few  of  these  supposed  examples  have  been 
verified  by  an  autopsy,  in  every  instance  in  which  the  autopsy  has 
been  made,  the  dislocation  has  been  found  to  be  complicated  with  a 
fracture,  generally  of  the  lower  extremity  of  the  radius  or  of  the  styloid 
apophysis  of  the  ulna. 

The  existence  of  a  complication,  however,  does  not  render  the  acci- 
dent any  the  less  a  dislocation,  although  it  may  render  the  diagnosis 
more  difficult,  and  modify  somewhat  the  indications  of  treatment.  A 
knowledge  of  the  fact  also  that  such  complications  have  always  been 
observed  in  the  autopsy  may  leave  us  in  doubt  as  to  what  is  the  natural 
history  of  a  simple,  uncomplicated  dislocation,  if,  indeed,  it  does  not 
warrant  a  suspicion  that  such  a  case  never  occurs.  We  shall,  never- 
theless, after  a  careful  analysis  of  the  cases  as  they  have  been  reported, 
and  by  a  consideration  of  the  anatomy  of  this  articulation,  be  able  to 
determine  with  some  degree  of  accuracy,  perhaps,  what  are,  or  what 
ought  to  be  the  usual  causes,  signs,  treatment,  &c.,  of  these  accidents. 

Partial  luxations  have  also  been  frequentl}''  described  by  surgeons. 
I  have  never  met  with  an  example,  but  the  following  case,  related  to 
me  by  the  patient  himself,  I  believe  to  have  been  a  case  in  point. 

Lewis  C,  of  Buffalo,  set.  18,  by  a  fall  upon  his  hand,  broke  the  left 
forearm  below  the  middle,  and  at  the  same  time,  as  he  affirms,  par- 
tially dislocated  the  carpal  bones  backwards.  Dr.  Spaulding,  of 
Williamsville,  N.  Y.,  who  is  now  dead,  took  charge  of  the  limb,  and 
pronounced  it  a  fracture  with  partial  dislocation,  and  for  more  than  a 
year  after  the  accident,  the  bones  had  a  tendency  to  become  displaced 
in  the  same  direction.  Whenever  he  attempted  to  lift  even  the  weight 
of  half  a  pound,  with  his  hand  supine  and  his  forearm  extended 
horizontally,  the  lower  end  of  the  radius  would  spring  suddenly  for- 
wards, and  all  power  in  the  arm  would  be  lost.  When  this  happened, 
as  it  did  quite  often,  he  always  reduced  the  bones  himself,  by  simply 
pushing  upon  them  in  the  direction  of  the  articulation. 

Fourteen  years  after  the  accident,  I  examined  the  arm  and  found  it 
in  all  respects  perfect,  except  that  the  forearm  was  shortened  about 


DISLOCATIONS    OF    THE    CARPAL    BONES   BACKWAEDS.      697 

one-third  of  an  inch,  which  shortening  was  due,  no  doubt,  to  the  over- 
lapping of  the  broken  bones. 


§  1.  Dislocations  op  the  Carpal  Bones  Backwards. 

Causes. — The  same  casualty,  namely,  a  fall  upon  the  palm  of  the 
hand,  which,  as  we  have  elsewhere  noticed,  produces  frequently  a 
fracture  of  the  lower  end  of  the  radius,  occasionally  a  dislocation  of 
the  radius  and  ulna  backwards,  at  the  elbow-joint,  may  also,  it  is 
believed,  occasion  sometimes  a  dislocation  of  the  carpal  bones  back- 
wards. In  several  of  the  cases  reported,  this  cause  has  been  assigned  ; 
but  in  the  only  example  of  simple  dislocation  which  has  ever  come 
under  my  notice,  and  which  I  have  every  reason  to  believe  was  a 
simple  dislocation  unaccompanied  with  a  fracture,  the  carpal  bones 
were  thrown  back  by  a  fall  upon  the  back  of  the  hand.  The  follow- 
ing is  a  brief  account  of  the  case : — 

The  Rev.  Stephen  Porter,  of  Geneva,  N.  Y.,  set.  75,  while  walking 
with  his  son  after  dark,  and  holding  in  his  right  hand  a  satchel,  slipped 
and  fell.  In  the  effort  to  save  himself,  and  still  retaining  his  grasp 
upon  the  satchel,  his  right  hand  struck  the  side-walk  flexed,  and  in 
such  a  way  as  that  the  whole  force  of  the  fall  was  received  upon  the 
back  of  the  hand  and  wrist,  thus  throwing  the  hand  into  a  state  of 
extreme  flexion.  In  less  than  twenty  minutes  he  was  at  my  house. 
No  swelling  had  yet  occurred,  and  the  moment  I  looked  at  the  wrist 
I  said  to  him,  "  You  have  broken  your  arm  ;"  so  much  did  it  resemble 
a  fracture  of  the  lower  end  of  the  radius.  A  farther  examination  led 
me  to  a  different  conclusion.  The  palmar  surface  of  the  wrist  pre- 
sented an  abrupt  rising  near  the  radio-carpal  articulation,  the  summit 
of  which  was  on  the  same  plane  and  continuous  with  the  bones  of  the 
forearm,  and  a  corresponding  elevation  existed  upon  the  dorsal  surface 
terminating  in  the  carpal  bones  and  hand ;  the  hand  was  slightly 
inclined  backwards,  but  the  fingers  were  moderately  flexed  upon  the 
palm.  To  this  extent  the  accident  bore  the  features  of  a  fracture  of 
the  radius ;  but  the  hand  did  not  fall  to  the  radial  side ;  the  projec- 
tions upon  the  palmar  and  dorsal  surfaces  were  more  abrupt  than  I 
had  ever  seen  in  a  case  of  fracture,  and  which,  if  it  were  a  fracture, 
would  imply  that  the  broken  extremities  had  been  driven  off'  from 
each  other  completely;  the  most  salient  angles  of  these  projections 
were  abrupt,  but  not  sharp  or  ragged ;  the  styloid  apophyses  could  be 
distinctly  felt,  and  I  was  not  only  able  to  determine  that  they  were 
not  broken,  but  by  observing  their  relations  to  the  palmar  and  dorsal 
eminences,  it  was  easy  to  see  that  these  latter  corresponded  to  the 
situation  of  the  articulation. 

In  addition  to  these  evidences  that  I  had  to  deal  with  a  dislocation, 
and  not  a  fracture,  we  had  the  testimony  furnished  by  the  reduction, 
which  was  not  made,  however,  until  by  every  possible  means  the 
diagnosis  was  definitely  settled.  Seizing  the  hand  of  the  gentle- 
man with  my  own  hand,  palm  to  palm,  and  making  moderate  but 
steady  extension  in  a  straight  line,  the  bones  suddenly  resumed  their 


598  DISLOCATIONS    OF    THE    WEIST. 

places  with  the  usual  sensation  or  sound  accompanying  reductions. 
There  was  no  grating,  or  chafing,  or  crushing,  nor  was  the  reduction 
accomplished  gradually,  but  suddenly.  To  test  still  further  the  accu- 
racy of  the  diagnosis,  I  now  pressed  forcibly  upon  the  wrist  from  before 
back,  but  without  producing  any  degree  of  displacement,  nor  could 
any  crepitus  still  be  detected.  No  splint  was  applied,  and  on  the  fol- 
lowing morning  Mr.  Porter  preached  from  one  of  the  pulpits  in  this 
city,  only  retaining  his  arm  in  a  sling. 

Sixteen  months  after  the  accident,  Sept.  15,  1858,  this  gentleman 
again  called  upon  me  and  I  found  the  arm  perfect  in  all  respects, 
except  that  it  was  not  quite  as  strong  as  before,  the  lower  extremity 
of  the  ulna  was  preternaturally  movable,  and  occasionally  he  felt  a 
sudden  slipping  in  the  radio-carpal  articulation. 

Pathological  Anatomy. — In  the  examples  of  compound  or  compli- 
cated dislocations,  which  alone  have  been  exposed  by  dissections,  the 
posterior  and  lateral  ligaments  have  been  found  extensively  torn,  as 
also  frequently  the  anterior  ligament,  with  or  without  separation  of 
the  radial  or  ulnar  apophyses ;  the  extensor  muscles  torn  up  from  the 
lower  part  of  the  forearm  and  displaced ;  the  first  row  of  the  carpal 
bones  lying  underneath  the  tendons,  and  upon  the  bones  of  the  fore- 
arm, sometimes  having  been  carried  directly  upwards,  sometimes  up- 
wards and  a  little  inwards,  and  at  other  times  upwards  and  outwards; 
the  arteries  and  nerves  have  occasionally  escaped  serious  injury,  but 
more  often  they  have  been  displaced,  bruised,  or  torn  asunder. 

Such  are,  briefly,  the  pathological  circumstances  which  may  be  sup- 
posed to  exist,  in  a  lesser  or  greater  degree,  in  nearly  all  cases  of  simple 
dislocations. 

Fig.  242. 


Dislocation  of  the  carpal  tones  backwards.    (From  Fergusson.) 

In  compound  dislocations,  however,  the  muscles,  or  rather  the  ten- 
dons, are  twisted,  torn,  and  thrust  aside,  producing  very  extensive 
lesions  among  the  deeper  structures  of  the  forearm  and  hand  before 
the  integuments  can  be  made  to  yield. 

On  the  2d  of  May,  1852,  Silas  Usher,  set.  54,  had  his  right  arm 
caught  between  the  bumpers  of  two  cars,  bruising  the  hand  and  dislo- 
cating the  carpal  bones  backwards,  the  radius  and  ulna  being  thrown 
forwards  and  pushed  completely  through  the  skin  into  the  palm  of  the 


DISLOCATIONS    OF    THE    CAEPAL    BONES    BACKWARDS.      599 

band.  Most  of  the  flexor  tendons  had  been  merely  thrust  aside,  but 
one  or  two  were  torn  asunder;  the  median  nerve  was  torn  off,  but  the 
radial  and  ulnar  nerves  were  apparently  uninjured,  and  there  was 
no  fracture.  The  patient  being  a  temperate  man,  in  perfect  health, 
and  the  bones  having  been  easily  replaced  by  moderate  extension,  it 
was  determined  to  make  an  effort  to  save  the  arm.  The  limb  was 
therefore  laid  on  a  carefully  padded  splint,  and  cool  water  lotions  dili- 
gently applied.  Phlegmonous  erysipelas  began  to  develop  itself  on 
the  third  day;  and  on  the  ninth,  gangrene  having  attacked  the  limb, 
I  amputated  a  little  above  the  middle  of  the  humerus.  On  the  four- 
teenth day  hemorrhage  occurred  suddenly  from  the  stump,  and  when 
I  reached  him  he  was  pulseless  and  dying. 

The  result  demonstrated  the  error  of  the  attempt  to  save  the  limb 
without  resection  of  the  lower  ends  of  the  bones  of  the  forearm. 

Symptoms. — The  usual  signs  have  already  been  sufficiently  stated  in 
the  example  which  we  have  given.  The  most  important  diagnostic 
marks  are  found  in  the  abruptness  of  the  angles  formed  by  the  project- 
ing bones;  the  relation  of  these  prominences  to  the  styloid  apophyses ; 
in  the  total  absence  of  crepitus;  and  in  the  reduction,  which  is  accom- 
plished easily,  suddenly,  and  with  a  characteristic  sensation.  If  a 
fracture  complicates  the  accident,  crepitus  may  also  be  present.  It 
should  be  remembered,   moreover, 

that  when  the  styloid  process  of  the  Fig-  243. 

radius  is  broken,  if  the  hand  is 
moved  backwards  and  forwards  this 
process  will  move  also,  which  might 
lead  to  the  supposition  that  the  ra- 
dius was  broken  higher  up,  and  that 
it  was  not  a  dislocation  at  all, 

J  '  .      \  ^ .  Dislocation  of  the  carpal  bones  backwards, 

cations  the  prognosis  is  exceeding    (From  sitey.) 
grave,  unless  the  surgeon  determines 

to  resort  to  amputation,  or,  what  is  generally  much  preferable,  to  re- 
section. In  dislocations  complicated  with  fracture  of  the  posterior 
edge  of  the  articulating  surface  of  the  radius  ("Barton's  fracture"^), 
some  difficulty  may  be  experienced  in  retaining  the  bones  in  place ; 
but  when  this  fracture  does  not  exist,  the  posterior  margin  of  the 
articulation,  considerably  elevated  above  its  anterior  margin,  consti- 
tutes a  sufficient  protection  against  a  reluxation  in  that  direction.  In 
all  cases,  also,  complicated  with  fracture,  even  of  an  apophysis,  intense 
inflammation  and  swelling  are  likely  to  follow,  and  the  danger  of  a 
permanent  anchylosis  is  greatly  increased. 

Treatment. — Extension  in  a  straight  line  has  generally  been  found 
sufficient  to  accomplish  the  reduction  ;  to  which  may  be  added  a  slight 
rocking  or  lateral  motion,  if  necessary. 

The  reduction  may  be  effected  also  by  pressing  the  hand  backwards, 
while  the  surgeon  pushes  the  carpus  downwards  from  behind  and 
above,  in  the  direction  of  the  articulation. 

1  Philadelphia  Medical  Examiner,  1838. 


600 


DISLOCATIONS    OF   THE   WEIST. 


Unless  a  tendency  to  displacement  exists,  no  splints  or  bandages  of 
any  kind  ought  to  be  applied,  but  it  should  be  treated  by  rest  and  cool 
water  lotions  until  all  danger  from  inflammation  has  passed. 


Dislocation  of  the  carpal  bones  forwards.     (From 
Fergusson.) 


§  2.  Dislocations  op  the  Carpal  Bones  Forwards. 

The  causes,  mechanism,  symptoms,  pathology,  treatment,  &c.,  of  this 

accident  resemble    in    so    many 
Fig.  244.  points   those   of   the   preceding 

dislocation,  with  only  the  differ- 
ences necessarily  due  to  a  change 
in  the  direction  of  the  bones,  that 
I  find  it  not  worth  while  to  do  / 
more  than  to  relate  one  single 
example  contained  in  Bransby 
Cooper's  edition  of  Sir  Astley's 
work  on  Fractures  and  Disloca- 
tions. The  case  did  not  come 
under  the  observation  of  Mr. 
Cooper  himself,  but  was  related 
to  him  by  Mr.  Haydon,  a  sur- 
geon residing  in  London.  It  :s 
especially  interesting  as  furnisli- 
ing  an  example  of  a  dislocation 
of  both  wrists  at  the  same  mo- 
ment, and  from  similar  causes,  but  in  opposite  directions. 

A  lad,  aged  about  thirteen  years,  was  thrown  violently  from  a 
horse  on  the  11th  of  June,  1840,  striking  upon  the  palms  of  both 
hands  and  upon  his  forehead.  The  left  carpus  was  found  to  be  dis- 
located backwards,  the  radius  lying  in  front  and  upon  the  scaphoides 
and  trapezium.  The  right  carpus  was  dislocated  forwards,  the  radius 
and  ulna  projecting  posteriorly,  and  the  bones  of  the  carpus  forming 
an  "irregular  knotty  tumor,  terminating  abruptly"  anteriorly. 

A  very  careful  examination  was  made  to  determine  what  parts 
came  in  contact  with  the  resisting  force,  but,  although  the  palms  of 
both  hands  were  extensively  bruised,  there  was  not  the  slightest 
bruise  on  the  back  of  either  hand.  Nor  were  the  gentlemen  present 
able  to  find  any  evidence  whatever  that  the  dislocation  was  accom- 
panied with  a  fracture.  "More- 
over," says  Mr.  Haydon,  "we  were 
strengthened  in  our  opinion  that 
this  was  a  case  of  dislocation,  un- 
attended with  any  fracture,  because 
the  dislocations  appeared  so  perfect; 
the  two  tumors  in  each  member  so 
distinct ;  the  reduction  so  complete; 
the  strength  of  the  parts  after  re- 
duction so  great ;  and,  lastly,  by  the 
very  trifling  pain  felt  after  reduction,  for  within  an  hour  after,  the 


Fi?.  245. 


Dislocation  of  the  carpal  bones  forwards. 
Skey.) 


(From 


DISLOCATIONS    OF    LOWER    EXD    OF    ULNA    BACKYTAEDS.      601 

patient  could  rotate  the  hand  and  supinate  it  when  prone — this  could 
not,  we  believe,  have  been  dope  had  there  existed  a  fracture.'' 


CHAPTER    XI 


DISLOCATIONS   OF  THE  LOWER   EXD   OF  THE   ULXA 
(IXFEEIOE   EADIO-ULXAE  AETIC  UL  ATIOX). 

Ix  connection,  with  fractures  of  the  lower  end  of  the  radius  this 
accident  is  not  very  uncommon.  I  have  myself  met  with  it  under 
these  circumstances  several  times:  but  without  a  fracture  it  is  quite 
rare.  Dupuytren  met  with  but  two  cases  in  his  long  and  extensive 
practice.  Sir  Astley  Cooper  does  not  record  a  single  instance,  and 
many  surgeons  affirm  that  they  have  never  seen  the  dislocation  in 
question. 


§  1.  Dislocations  of  the  Lower  Ent)  of  the  TJlxa  Backwards. 

To  the  eleven  or  twelve  examples  collected  and  referred  to  by 
Malgaigne,  I  am  only  able  to  add  one  case  of  ancient  luxation  seen 
by  myself. 

Causes. — Duges  mentions  the  case  of  a  little  girl  in  whom  the  ac- 
cident occurred  in  both  arms,  but  at  different  periods,  by  being  lifted 
by  the  hands.  One  of  the  patients  seen  by  Desault,  a  child  five  years 
old,  had  the  ulna  dislocated  backwards  by  extension  accompanied 
with  forced  pronation,  and  in  another  example  cited  by  him  forced 
pronation  alone,  as  in  wringing  wet  clothes,  was  found  to  have  been 
sufficient.     In  Hurteaux's  case  the  patient  had  fallen  upon  her  wrist. 

Pathological  Anatomy. — Eupture  of  the  synovial  membrane  (sacci- 
form ligament),  and  also  of  the  ligament  which  binds  the  ulna  to  the 
cuneiform  bone :  the  little  head  or  lower  extremity  of  the  ulna  aban- 
doning its  socket  in  the  radius,  and  being  thrown  backwards,  or  in 
some  cases  backwards  and  outwards  so  as  to  cross  obliquely  the  lower 
end  of  the  radius;  or  it  may  incline  inwards  as  well  as  backwards. 

Several  examples  are  mentioned  also  in  which  the  end  of  the  bone 
has  been  thrust  completely  through  the  integuments. 

Prognosis. — In  recent  cases  the  reduction  has  generally  been  accom- 
plished without  difficulty,  and  in  only  three  or  four  instances  has  the 
bone  become  spontaneously  displaced. 

Loder  reduced  the  ulna  after  eight  weeks,  and  Eognetta  after  sixty 
days.  In  the  example  to  which  I  have  already  referred  as  having 
been  seen  by  myself,  the  dislocation  had  existed  twenty  years,  the  ac- 


602      DISLOCATIONS    OF    THE    LOWEE    END    OF    THE    ULNA. 

cident  having  occurred  in  Ireland  when  the  person  was  fifteen  years 
old.  When  I  examined  the  arm,  July  21,  1850,  the  right  ulna  pro- 
jected backwards  and  a  little  outwards,  about  half  an  inch.  He  said 
he  had  been  lame  with  it  for  several  years,  but  the  motions  of  the 
wrist  joint  were  now  completely  restored,  and  both  pronation  and 
supination  were  perfect. 

Sy'm2')ioms. — The  hand  is  usually  fixed  in  a  position  midway  between 
supination  and  pronation.  Boyer,  however,  found  the  hand  in  a  state 
of  extreme  pronation.  The  extremity  of  the  ulna  is  felt  and  seen 
distinctly  upon  the  back  of  the  wrist,  prominent  and  movable ;  and 
the  styloid  process  is  no  longer  in  a  line  with  the  metacarpal  bone  of 
the  little  finger ;  the  fingers,  hand  and  forearm  are  slightly  flexed. 

Treatment. — The  reduction  may  be  accomplished  by  holding  firmly 
upon  the  radius  and  at  the  same  moment  pushing  the  ulna  forcibly 
toward  its  socket ;  or  by  simply  supinating  the  hand  strongly.  Some 
cases  demand  also  extension  with  counter-extension. 

Generally  the  bone  has  been  found  to  remain  in  its  place  without 
assistance,  yet  in  three  or  four  of  the  examples  upon  record  the  con- 
stant tendency  to  displacement  when  the  pressure  was  removed,  has 
rendered  it  necessary  to  employ  splints  and  compresses. 


§  2.  Dislocation  of  the  Lower  End  of  the  Ulna  Forwards. 

The  dislocation  forwards  is  said  by  Malgaigne  to  be  more  rare  than 
the  dislocation  backwards.  In  addition  to  the  nine  cases  collected  by 
him,  T  have  been  able  to  add  one  reported  by  Parker,  of  Liverpool ; 
leaving,  therefore,  a  difference  of  only  three  or  four  in  favor  of  the 
luxation  backwards ;  and  not  sufficient,  I  think,  to  warrant  any  posi- 
tive conclusions  as  to  the  relative  frequency  of  the  two  accidents. 

While  the  dislocation  backwards  is  usually  caused  by  violent  pro- 
nation of  the  hand,  this  dislocation  is  most  often  occasioned  by  violent 
supination.  The  hand  is  therefore  generally  found  to  be  supinated  for- 
cibly, and  the  projection  formed  by  the  end  of  the  bone  is  seen  upon 
the  front  of  the  wrist  instead  of  the  back. 

By  pushing  the  ulna  toward  its  socket  while  an  attempt  is  made  to 
flex  the  hand,  or  by  extension,  supination,  &c.,  it  is  made  to  resume  its 
position  readily.  In  the  case  reported  by  Parker,  however,  the  re- 
duction was  effected  only  while  the  hand  was  prone. 

Parker's  case,  already  referred  to,  is  thus  related : — 

"John  Dalton,  aged  forty,  applied  to  the  hospital  Aug.  9th,  1841, 
under  the  following  circumstances : — 

"States  that  he  is  a  carter,  and  falling  down,  the  shaft  of  the  cart 
fell  upon  his  hand  and  forearm,  in  such  a  way  as  to  supinate  them 
forcibly.  He  complains  of  pain  in  the  left  wrist.  The  forearm  is 
supinated,  and  cannot  be  pronated,  the  attempt  causing  much  suffering. 
The  wrist-joint  can  be  flexed  or  extended  without  much  pain.  On 
looking  at  the  back  of  the  wrist,  the  appearance  is  characteristic ;  the 
natural  prominence  of  the  ulna  is  wanting;  an  evident  depression  ex- 
ists, as  if  the  lower  end  of  the  ulna  had  been  dissected  out;  it  can  be 


DISLOCATIONS    OF    THE    CAEPAL    BONES.  603 

traced,  however,  on  a  plane  anterior  to  the  radius,  its  button-like  head 
being  distinctly  felt  under  the  flexor  tendons.  Several  ineffectual  and 
very  painful  attempts  were  made  to  accomplish  the  reduction,  by 
pushing  the  head  of  the  ulna  into  its  natural  situation.  This  was  at 
last  effected  by  seizing  the  hand  to  make  extension  (counter-extension 
being  made  at  the  elbow),  then  forcibly  pronating  the  hand,  at  the 
same  time  pressing  backwards  the  dislocated  head  of  the  bone  with 
the  fingers  of  the  left  hand.  After  persevering  for  a  short  tinie,  the 
bone  was  felt  to  assume  its  natural  position,  the  wrist  acquired  its 
usual  appearance,  and  the  ordinary  movements  of  the  joint  could  be 
readily  performed.  There  was  no  tendency  to  re-dislocation,  and  the 
man  was  dismissed  with  directions  to  keep  the  joint  quiet,  and  to 
foment  it.  He  attended  as  an  out  patient  for  two  or  three  days,  after 
which,  complaining  of  nothing  but  a  little  weakness  in  the  part,  a 
bandage  was  applied,  and  ordered  to  be  worn  for  a  short  time.'" 


CHAPTER    XII. 


DISLOCATIONS   OF  THE  CARPAL  BONES    (AMONG 
THEMSELVES). 

Bound  together  on  all  sides  by  strong  ligaments,  and  enjoying  only 
a  very  limited  degree  of  motion  among  themselves,  the  carpal  bones 
seldom  become  displaced  except  in  gunshot  wounds,  or  in  connection 
with  extensive  lacerations  and  fractures  of  the  neighboring  parts. 
Simple  dislocations,  or  rather  sub-luxations  of  these  bones  do,  how- 
ever, occasionally  take  place,  but  so  far  as  we  have  been  able  to 
ascertain,  only  in  one  direction,  namely,  backwards. 

The  bones  of  the  carpus,  which  are  said  occasionally  to  have  suffered 
simple  backward  subluxation,  are  the  os  magnum,  cuneiforme,  unci- 
forme,  and  pisiforme. 

Eicherand,  the  editor  of  Boyer's  Lectures,  says  that  he  once  met 
with  a  subluxation  of  the  os  magnum  backwards,  of  which  he  has 
given  us  the  following  account :  "  Mrs.  B.,  in  a  labor  pain,  seized 
violently  the  edge  of  her  mattress,  and  squeezed  it  forcibly,  turning  her 
wrist  forwards  ;  she  instantly  heard  a  slight  crack,  and  felt  some  pain, 
to  which  her  other  sufferings  did  not  allow  her  to  attend.  Fifteen 
days  afterwards,  happily  delivered,  and  recovered  by  the  care  of 
Professor  Baudelocque,  she  showed  her  left  hand  to  this  celebrated 
accoucheur,  and  expressed  her  disquietude  about  the  tumor  which 
appeared  on  it,  especially  when  much  bent.     I  was  called  to  visit  the 

'  Parker,  Amer.  Joum.  Med.  Sci.,  April,  1843,  p.  470  ;  from  Loud,  and  Edin.  Moiitli. 
Journ.  Med.  Sci.,  Dec.  1842. 


604  DISLOCATIONS    OF    THE    CARPAL    BONES. 

lady.  I  found  that  this  hard  circumscribed  tumor,  which  disappeared 
almost  totally  by  extending  the  hand,  was  formed  by  the  head  of  the 
OS  magnum,  luxated  backwards;  I  replaced  it  entirely  by  extending 
the  hand,  and  making  gentle  pressure  on  it.  As  the  affection  did  not 
impede  the  motion  of  the  part,  as  the  tumor  disappeared  on  extending 
the  hand,  and  as  it  would  have  been  even  little  apparent  in  any  state 
of  the  hand  had  Mrs.  B.  been  more  in  flesh,  I  advised  her  not  to  be 
uneasy  about  it,  and  to  apply  no  remedy  to  it."^ 

Eicheraud  adds  also  that  Boyer  and  Chopart  had  each  met  with  the 
same  dislocation. 

Bransby  Cooper  saw  the  os  magnum  displaced  backwards  in  a 
stout,  muscular  young  man  by  a  fall  upon  the  back  of  the  hand  when 
in  extreme  flexion.  The  hand  remained  slightly  bent,  and  the  pro- 
jection of  the  OS  magnum  was  very  distinct.  Eeduction  was  attempted 
by  extending  the  whole  hand,  at  the  same  time  making  pressure  upon 
the  displaced  bone;  this  not  succeeding,  extension  was  made  from 
the  middle  and  forefingers  only,  while  pressure  was  kept  up  on  the  os 
magnum,  when  suddenly  the  bone  resumed  its  natural  position.  On 
flexing  the  hand,  however,  the  dislocation  was  immediately  repro- 
duced ;  and  it  became  necessary  to  apply  a  compress  and  splint.  For 
several  days  after,  he  was  in  the  habit  of  pushing  it  out  by  flexing  the 
hand,  in  order  that  the  young  men  at  Guy's  Hospital  might  see  its 
reduction ;  which  was  always  easily  accomplished  by  simply  pushing 
upon  it. 

Sir  Astley  says  that  both  the  os  magnum  and  cuneiforme  are 
sometimes  thrown  a  little  backwards,  from  simple  relaxation  of  the 
ligaments,  producing  a  great  degree  of  weakness  so  as  to  render  the 
hand  useless  unless  the  wrist  be  supported ;  and  he  mentions  the  case 
of  a  young  lady  in  whom  the  os  magnum  was  thus  displaced  and  who 
was  obliged  to  give  up  her  music  in  consequence ;  for  when  she  wished 
to  use  her  hand  she  was  compelled  to  wear  two  short  splints,  made 
fast  to  the  back  and  forepart  of  the  hand  and  forearm.  Another  lady 
whose  hand  was  weak  from  a  similar  cause,  wore  for  the  purpose  of 
giving  it  strength,  a  strong  steel  chain  bracelet,  clasped  very  tightly 
around  the  wrist.* 

Gras  has  described  a  dislocation  of  the  pisiform  bone,^  and  Fergus- 
son  says  he  has  known  an  example  in  which  this  bone  was  detached 
from  its  lower  connections  by  the  action  of  the  flexor  carpi-ulnaris." 
Little  benefit,  he  thinks,  can  be  expected  from  any  attempts  to  keep 
it  in  place  when  it  is  dislocated,  nor  is  its  displacement  of  much 
consequence.  Erichsen  thinks  he  has  seen  a  dislocation  of  the  os 
lunare  produced  by  a  fall  upon  the  hand  when  forcibly  flexed.  By 
extension  and  pressure  it  was  easily  replaced,  but  when  the  hand  was 
flexed  the  dislocation  was  immediately  reproduced.* 

Notwithstanding  that  Sir  Astley,  Miller,  and  others  have  taught 
that  the  cuneiform   bone  is  liable  to  displacement,  and   South  has 

'  Richerand,  Boyer's  Lectures  on  Diseases  of  Bones,  Amer.  ed.,  1 805,  p.  261. 

■2  Sir  A.  Cooper,  op.  cit.,  p.  435.  ^  Note  to  Chelius  by  South,  op.  cit.,  p.  234. 

*  Fergusson,  op.  cit.,  p.  190. 

^  Erichsen,  Science  and  Art  of  Surg.,  Amer.  ed.,  1859,  p.  259. 


DISLOCATIOX    OF    THE    ilETACAEPAL    BOXES.  605 

aflflrmed  the  same  of  the  unciform,  I  have  found  no  account  of  an 
example  of  simple  dislocation  of  single  carpal  bones  except  in  the 
cases  of  the  os  magnum,  pisiformis,  and  lunare,  as  above  mentioned. 

Maisonneuve  has  reported  an  example  of  simple  dislocation,  without 
wound  of  the  integuments,  at  the  middle  carpal  articulation.  A  man 
had  fallen  forty  feet,  and  was  carried  dying  to  the  Hotel  Dieu.  The 
symptoms  were  almost  precisely  those  of  a  dislocation  of  both  rows  of 
the  carpal  bones  backwards.  The  reduction  was  not  accomplished 
during  life,  but  after  death  a  simple  effort  of  traction  was  sufficient  to 
replace  the  bones.  The  dissection  showed  that  the  bones  of  the  second 
row  were  almost  completely  separated  from  those  of  the  first,  upon 
which  they  were  overlapped  backwards.  A  small  fragment  of  both 
the  scaphoides  and  cuneiform  remained  attached  to  the  second  row, 
but  with  this  exception,  the  separation  was  complete.^ 


CHAPTEE,    XIII. 

DISLOCATIOX  OF  THE  :srETACARPAL  BOXES   (AT  THE 
CARPO-META CARPAL   A RTICULATIOXS). 

The  metacarpal  bone  of  the  thumb  may  be  dislocated  either  back- 
wards or  forwards.  The  former  is  the  most  frequent;  and  it  is  pro- 
duced generallj'  by  a  fall  upon  the  thumb,  which  throws  it  into  a  state 
of  extreme  flexion ;  it  has  also  been  occasioned  by  a  force  acting  in 
an  opposite  direction,  as  when  a  flash  of  powder  is  exploded  in  the 
palm  of  the  hand,  or  a  blow  is  received  upon  the  extremity  and  volar 
aspect  of  the  last  phalanx. 

The  dislocation  may  be  partial  or  complete.  In  the  few  examples 
of  partial  dislocation  which  have  been  recorded,  the  position  of  the 
finger  has  been  either  moderately  flexed  or  straight,  and  the  signs  of 
the  accident  have  been  occasionally  so  obscure  as  to  have  led  to  an 
error  in  the  diagnosis,  and  the  luxation  has  remained  unreduced. 
When  the  dislocation  is  recognized,  reduction  is  in  most  cases  easily 
accomplished  by  pressure,  combined  with  extension ;  after  which  it 
is  sometimes  necessary  to  apply  a  splint  to  maintain  the  apposition. 
If  the  reduction  is  not  accomplished  the  joint  is  permanently  maimed. 

Complete  backward  luxations  are  more  frequent  than  incomplete, 
and  are  produced  by  the  same  class  of  causes;  generally  by  a  fall  upon 
the  palmar  surface  of  the  thumb. 

The  symptoms  are  sufficiently  clear,  although  the  position  of  the 
thumb  is  not  always  the  same.  It  has  been  found  perfectly  straight, 
without  any  inclination  either  way,  or  flexed  more  or  less,  with  the 

'  Maisonneuve,  Malgaigne,  op.  cit.,  from  ilfim.  de  la  Soo.  de  Chirurg.,  t.  ii. 


606  DISLOCATION    OP    THE    METACARPAL    BONES. 

metacarpal  bone  also  inclined  inwards  toward  the  palm.  The  motions 
of  the  joint  are  interrupted,  and  the  proximal  extremity  of  the  meta- 
carpal bone  riding  upon  the  back  of  the  trapezium,  projects  sensibly 
in  this  direction,  and  the  trapezium  is  also  felt  unusually  prominent 
under  the  thenar  eminence.  The  overlapping  varies  from  a  line  or 
two  to  three-quarters  of  an  inch.  In  the  patient  mentioned  by  Bour- 
guet,  the  head  of  the  metacarpal  bone  almost  reached  the  styloid  pro- 
cess of  the  radius. 

The  reduction  is  to  be  e&ected  by  extension  alone,  or  by  extension 
with  moderate  pressure. 

In  two  of  the  examples  reported,  although  the  reduction  was  accom- 
plished very  easily,  the  dislocation  was  reproduced  when  the  extension 
ceased,  and  it  became  necessary  to  apply  splints.  Malgaigne  did  not 
observe  in  the  case  seen  by  him,  any  such  tendency  to  displacement. 

In  the  case  of  Bourguet's  patient  the  reduction  was  never  accom- 
plished, although  the  attempt  was  made  on  the  second  day  by  a  sur- 
geon, and  repeated  after  about  two  months  by  Bourguet  himself 

Fergusson,  who  has  met  with  several  of  these  dislocations,  says  that 
he  has  seen  even  a  splint  and  roller  fail  of  keeping  the  bones  in  place; 
and  he  recommends,  for  the  purpose  of  security,  that  the  splint  should 
extend  some  distance  upon  the  forearm. 

Sir  Astley  Cooper  says  that  in  the  cases  of  this  accident  which  he 
has  seen  the  metacarpal  bone  of  the  thumb  has  been  thrown  inwards, 
between  the  trapezium  and  the  root  of  the  metacarpal  bone  supporting 
the  forefinger;  forming  a  protuberance  toward  the  palm  of  the  hand; 
the  thumb  has  been  bent  backwards,  and  adduction  was  impossible. 

This  distinguished  surgeon  cites  no  examples,  nor  are  we  able  to 
find  upon  record  an  instance  of  complete  inward  dislocation  of  this 
bone,  such  as  Sir  Astley  has  described. 

Vidal  (de  Cassis)  believes  that  he  has  met  with  a  partial  forward  dis- 
location, which  he  reduced  readily,  but  the  patient  having  removed 
the  retentive  means,  the  dislocation  was  reproduced  and  the  bone  was 
not  again  replaced.' 

Malgaigne  has  collected  only  three  examples  of  a  dislocation  of 
either  of  the  other  metacarpal  bones.  One,  observed  by  Bourguet, 
was  a  dislocation  forwards  of  the  metacarpal  bone  of  the  index  finger, 
having  been  caused  by  a  great  force  applied  to  the  back  of  the  phalanx 
near  the  carpus.  Eeduction  was  effected  by  extension  and  pressure, 
the  bone  resuming  its  place  insensibly  and  not  suddenly.  With  the 
aid  of  splints  it  was  retained  in  position,  and  the  cure  was  perfect. 
The  second,  seen  by  Roux,  was  a  backward  luxation  at  the  carpo- 
metacarpal articulation  of  the  second,  or  great  finger,  produced  by  an 
explosion  in  a  mine.  By  pressure  made  directly  upon  the  projecting 
bone  he  was  unable  to  reduce  it,  but  by  uniting  pressure  with  exten- 
sion from  the  finger,  he  succeeded  readily.  After  the  reduction  was 
effected,  it  was  noticed  that  when  the  hand  was  straightened  the  bone 
became  reluxated,  but  that  it  was  easily  kept  in  place  when  the  hand 
was  flexed.     The  third  example  (occurring  in  the  same  joint),  men- 

'  Vidal  (de  Cassis),  Traite  de  Pathologie  Externe,  etc.,  3d  Paris  ed.,  t.  ii.  p.  564. 


I 


FTEST    PHALANX    OF    THE    THUMB    BACKWAEDS.  607 

tioned  by  Malgaigne,  occasioned  by  a  fall  upon  the  clenched  hand, 
was  probably  incomplete,  and  Malgaigne  is  not  quite  certain  that  it 
was  not  a  fracture. 

In  April,  1849,  Stephen  Peterson,  ^t.  24,  was  admitted  into  the 
Buffalo  Hospital  of  the  Sisters  of  Charity,  with  a  partial  dislocation 
backwards  of  the  proximal  ends  of  the  metacarpal  bones  of  the  index 
and  great  fingers  of  the  right  hand  ;  produced,  as  he  affirms,  by  striking 
a  man  with  his  clenched  fist,  about  one  year  previous.  He  says  that 
he  called  upon  a  surgeon  immediately,  but  he  was  unable  to  keep  the 
bones  in  place.  The  projection  was  very  manifest  at  the  time  of  my 
examination,  and  the  hand  had  never  recovered  the  power  of  grasping 
bodies  firmly. 

During  the  same  year  I  found  in  the  hospital  a  precisely  similar  case, 
in  the  person  of  Francis  M'Coit,  set.  32,  a  sailor,  which  had  occurred 
four  years  before,  in  consequence  of  a  blow  given  with  his  fist.  The 
same  bones  were  partially  displaced  backwards,  and  remained  unre- 
duced. This  man  had  also  consulted  a  surgeon  soon  after  the  injury 
was  received. 

In  both  of  the  above  examples  I  instituted  a  careful  examination  to 
determine  whether  it  was  not  the  bones  of  the  carpus  thus  displaced ; 
but  the  result  was  conclusive  as  to  the  nature  of  the  accident,  and  I 
have  obtained  casts  of  both  in  order  to  illustrate  partial  dislocations 
of  the  metacarpal  bones. 


CHAPTER    XIV. 

DISLOCATIONS  OF  THE  FIEST  PHALANGES  OF  THE 
THUMB  AND  FINGEES  (AT  THE  MET  AC  AEP  0-PH  A- 
LANGEAL    A  ETIC  UL  ATIO  X  S  ). 

§  1.  Dislocations  of  the  First  Phalanx  or  the  Thumb  Backwards. 

This  bone  may  be  dislocated  backwards  or  forwards,  but  most  fre- 
quently the  dislocation  is  backwards. 

The  backward  dislocation  is  occasioned  generally  by  a  fall  or  blow 
upon  the  distal  end  and  palmar  surface  of  the  thumb;  the  proximal 
extremity  of  the  first  phalanx  sliding  back  upon  the  distal  extremity 
of  the  metacarpal  bone,  and  standing  oft'  from  it  at  nearly  a  right  angle, 
the  last  being  again  flexed  upon  the  first  phalanx  at  about  a  right  angle 
also;  meanwhile  the  distal  end  of  the  metacarpal  bone  is  seen  project- 
ing strongly  in  the  palm  of  the  hand.  (Fig.  246.) 

These  are  the  usual  signs  which  characterize  this  accident,  and  they 
are  always  sufficiently  diagnostic.     In  a  few  cases,  however,  the  pha- 


608 


OF   FIRST   PHALANGES    OF    THUMB    AND   FINGERS. 


Fig.  246. 


Dislocation  of  the  first 
phalanx  of  the  thumb  back- 
wards. 


langes  have  been  found  extended  upon  tlie  metacarpal  bone  in  almost 
a  straight  line,  indicating,  we  presume,  some  extraordinary  lesion  of 
the  tendons  or  muscles. 

The  reduction  is  sometimes,  in  recent  cases, 
accomplished  with  great  ease;  as  the  following 
examples  will  illustrate. 

A  servant  girl,  aet.  25,  fell  down  a  flight  of 
steps  Nov.  15,  1850,  striking  upon  the  inside  of 
her  right  hand  and  thumb.  When  I  saw  her, 
only  a  few  minutes  afterwards,  I  found  the  first 
phalanx  standing  back  almost  at  a  right  angle 
with  the  metacarpal  bone,  and  the  second  phalanx 
also  flexed  to  a  right  angle  with  the  first.  As- 
sisted by  my  pupil,  Mr.  Boardman,  the  reduction 
was  effected  in  about  twenty  seconds,  by  bending 
the  first  phalanx  farther  back,  and  at  the  same 
moment  pressing  the  proximal  end  of  this  pha- 
lanx forwards  in  the  direction  of  the  joint. 
Without  employing  great  force,  the  reduction 
took  place  suddenly  and  with  a  snap.  Very  little  swelling  followed, 
and  in  three  weeks  she  was  able  to  use  her  needle  without  incon- 
venience. 

Michael  Wolf,  set.  85,  fell  from  a  height  causing  a  fracture  of  his 
left'arra,  and  a  dislocation  of  his  right  thumb  backwards.  I  saw  him 
within  two  hours  after  the  accident.  The  thumb  was  much  swollen, 
and  its  position  the  same  as  in  the  case  just  described,  Althougb 
Wolf  was  a  strong,  muscular  man,  the  reduction  was  accomplished  in 
a  few  seconds  by  applying  over  the  last  phalanx  the  Indian  toy  called 
a  "puzzle,"  and  making  extension  in  a  straight  line,  while  an  assistant 
made  counter-extension  from  the  hand  and  wrist.  The  use  of  the  joint 
was  soon  completely  restored. 

Examples,  however,  are  constantly  occurring,  which  are  only  re- 
duced after  long  continued  and  painful  eflbrts,  or  which,  indeed,  com- 
pletely exhaust  the  patience  and  baffle  the  skill  of  the  most  experienced 
surgeons. 

Mary  J.  S.,  set.  23,  fell  upon  her  right  hand  with  her  fingers  and 
thumb  extended,  in  Sept.  1853,  and  dislocated  this  bone  backwards. 
A  young  surgeon  attempted  to  reduce  the  dislocation  half  an  hour  after 
the  accident,  by  the  same  manoeuvre  adopted  by  myself  successfully 
in  the  case  of  the  servant  girl ;  only  that  he  made  extension  upon  the 
last  phalanx  at  the  same  moment.  The  surgeon  believes  that  the 
bone  was  reduced,  but  one  week  later  he  found  it  displaced,  and,  as 
he  believes,  reduced  it  again.  The  same  thing  occurred  a  third  time. 
Six  months  after  this  the  girl  consulted  me  to  ascertain  what  could 
be  done  for  her  relief.  The  thumb  occupied  the  usual  position,  and 
admitted  of  no  motion  except  at  the  carpo-metacarpal  articulation. 

It  is  quite  probable  that  the  dislocation  was  never  reduced,  an  error 
which,  if  it  did  occur,  might  easily  be  excused,  when  we  remember 
that  from  the  first  the  thumb  was  greatly  swollen. 


FIEST   PHALANX   OF    THE    THUMB    BACKWAEDS.  609 

In  May,  1848,  having  been  called  to  see  Gr.  H,,  who  had  attempted 
suicide  by  cutting  his  throat,  my  attention  was  arrested  by  the 
appearance  of  his  left  thumb,  and  which  I  found  to  be  occasioned  by 
an  ancient  dislocation  of  the  first  phalanx  backwards.  The  accident 
had  occurred,  he  afterwards  told  me,  twelve  years  before,  in  conse- 
quence of  a  fall  while  wrestling.  A  very  respectable  country  surgeon 
was  called,  and  made  three  separate  attempts  to  reduce  it,  but  failed. 

The  several  bones  of  the  thumb  occupied  their  usual  positions,  that 
is  to  say,  the  positions  which  they  usually  occupy  in  this  dislocation, 
yet  notwithstanding  the  almost  complete  anchylosis  of  the  phalangeal 
articulations,  and  the  awkward  encroachment  of  the  distal  end  of  the 
metacarpal  bone  upon  the  palm,  the  hand  was  quite  useful. 

On  the  25th  of  July,  1857,  Catherine  Ernst  was  brought  to  me  by 
her  parents  having  a  dislocation  of  the  first  phalanx  of  the  right  hand, 
which  had  already  existed  some  days,  and  upon  which  several  un- 
successful attempts  at  reduction  had  been  made.  The  dislocation  was 
backwards,  but  the  phalanges,  instead  of  standing  at  a  right  angle  with 
each  other  and  with  the  metacarpal  bone,  as  is  usually  the  case,  were 
in  a  straight  line  with  each  other  and  parallel  with  the  metacarpal 
bone.  Whether  this  phenomenon  existed  from  the  first,  or  was  due 
to  the  efforts  already  made  at  reduction,  I  could  not  determine,  but  the 
same  thing  has  been  noticed  occasionally  by  other  surgeons.  The 
first  phalanx,  moreover,  instead  of  being  placed  directly  behind  the 
metacarpal  bone,  occupied  a  position  upon  its  back  a  little  to  the  ra- 
dial side  of  the  centre. 

During  quite  half  an  hour  I  made  continued  and  varied  attempts 
to  reduce  the  bone,  by  extension,  by  forced  dorsal  flexion,  and  by 
pressing  the  upper  end  of  the  first  phalanx  in  the  direction  of  the  joint 
while  pressure  was  made  against  its  lower  end  so  as  to  bring  it  into 
dorsal  flexion,  and  finally  by  calling  to  my  aid  the  "puzzle"  and  chlo- 
roform, but  all  to  no  purpose. 

One  week  later  I  repeated  these  efforts,  and  with  no  better  success. 
The  parents  peremptorily  refused  to  allow  me  to  cut  the  lateral  liga- 
ments or  flexor  tendons,  so  the  bone  remains  unreduced. 

Surgical  writers  have  recorded,  from  time  to  time,  a  great  many 
similar  cases,  and  it  is  asserted  upon  the  authority  of  Bromfield,  quoted 
by  Hey,  that  the  extending  force  has  been  increased  to  such  an  amount 
as  to  tear  off  the  last  phalanx  without  having  succeeded  in  reducing 
the  first;  but  while  surgeons  have  united  in  their  testimony  as  to  the 
exceeding  obstinacy  of  a  large  proportion  of  these  dislocations,  they 
are  far  from  being  agreed  as  to  the  source  of  the  difiiculty. 

Sir  Astley  Cooper  finds  a  sufficient  explanation  in  the  six  short  and 
powerful  muscles  which  are  inserted  into  the  first  and  last  phalanx, 
and  especially  in  the  flexors.'  Hey  believes  the  resistance  to  be  in 
the  lateral  ligaments  between  which  the  lower  end  of  the  metacarpal 
bone  escapes  and  becomes  imprisoned.     Ballingall,  Malgaigne,  Erich- 

'  Lawrie,  of  Glasgow,  says  that  Sir  Astley  in  a  conversation  with  him  declared  that 
the  "sesamoid  bones"  were  the  sources  of  the  difficulty.  See  Amer.  Journ.  Med. 
Sci.,  vol.  xxii.  p.  230,  with  observations  and  experiments  by  Lawrie. 

39 


610         OF    FIRST    PHALANGES    OF    THUMB   AND    FINGERS. 

sen,  and  Yidal  (de  Cassis)  think  the  metacarpal  bone  is  locked  between 
the  two  heads  of  the  flexor  brevis,  or  rather  between  the  opposing 
sets  of  muscles  which  centre  in  the  sesamoid  bones,  as  a  button  is 
fastened  into  a  button-hole,  Pailloux,  Lawrie,  Michel,  Leva,  Blechy, 
and  Koser  affirm  that  the  anterior  ligament  being  torn  from  one  of  its 
attachments  falls  between  the  joint  surfaces  and  interposes  an  effectual 
obstacle  to  reduction.  Dupuytren  ascribes  the  difficulty  to  the  altered 
relations  of  the  lateral  ligaments,  which  are  naturally  parallel  to  the 
axis  of  the  metacarpal  bone,  but  which  are  now  placed  at  a  right  angle ; 
to  the  spasm  of  the  muscles,  and  to  the  shortness  of  the  member,  in 
consequence  of  which  the  force  of  extension  has  to  be  applied  very 
near  to  the  seat  of  the  dislocation.  Lisfranc  found  in  an  ancient  lux- 
ation the  tendon  of  the  long  flexor  so  displaced  inwards  and  entangled 
behind  the  extremity  of  the  bone  as  to  prevent  reduction.  Deville 
discovered  in  an  autopsy  a  similar  displacement  of  this  tendon  out- 
wards. 

The  modes  of  reduction  practiced  and  recommended  by  these 
different  surgeons  are  as  diversified  and  irreconcilable  as  their  views 
of  the  mechanism  and  pathological  anatomy  of  the  accident. 

Sir  Astley  Cooper  recommends  that  extension  shall  be  made  by 
bending  the  thumb  toward  the  palm  of  the  hand,  to  relax  the  flexor 

muscles  as  much  as  possible ;  and  then, 
Pi    247.  by  fastening  a  clove  hitch  (Fig.  247), 

upon  the  first  phalanx,  previously  cover- 
ed with  a  piece  of  soft  leather,  the  exten- 
sion is  to  be  continued,  only  inclining 
the  thumb  a  little  inwards  toward  the 
palm  of  the  hand.  If  these  means  fail 
after  having  been  continued  a  consider- 
able length  of  time,  he  advises  that  a 
weight  shall  be  suspended  to  the  thumb, 
passing  over  a  pulley.  (Fig.  248.)  Fi- 
nally, in  the  event  of  the  failure  of  this 
method  also.  Sir  Astley  thought  that  no 
further  attempts  should  be  made,  and 
Clove  hitch.  especially  that  no  operation  for  the  divi- 

sion of  parts  was  justifiable. 
Lizars  and  Pirrie  adopt  the  views  of  Sir  Astley  with  little  or  no 
qualification. 

Charles  Bell  proposed  flexing  the  joint,  employing  also  at  the  same 
time  pressure ;  and  in  obstinate  cases  he  advised  subcutaneous  section 
of  the  lateral  ligaments  with  a  small  knife,  a  method  which  has  since 
been  practiced  successfully  by  Listen,  Eeinhardt,  Gibson,  of  Philadel- 
phia, Parker,  of  New  York,  and  others.  Syme  and  Lizars  justify  the 
practice  in  certain  cases.  Hey  declared  that  neither  extension  nor 
flexion  was  useful,  but  that  the  bones  could  be  best  brought  into 
place  by  pressure  alone. 

Eoser,  from  his  experiments  upon  the  cadaver,  concludes  that  the 
dislocated  phalanx  must  first  be  bent  forcibly  backwards,  or  into  the 


FIEST    PHALANX    OF    THE    THUMB    BACKWAEDS.  611 

position  termed  by  some  writers  dorsal  flexion,  so  as  to  throw  the 
head  of  the  phalanx  forwards  upon  the  articulating  surface  of  the 

Fig.  248. 


Sir  Astley  Cooper's  method  of  reducing  dislocations  of  the  thumb,  with  pulleys. 

metacarpal  bone.     Parker,  of  New  York,  in  his  notes  to  the  American 
edition  of  Samuel  Cooper's  work,  recommends  the  same  procedure. 

Vidal  (de  Cassis)  recommends  also  that  the  extension  should  be 
made  first  backwards,  so  as  to  increase  the  displacement  of  the  first 
phalanx  in  this  direction,  and  to  throw  forwards  its  articular  surface  in 
the  direction  of  the  articular  surface  of  the  metacarpal  bone. 

This  method,  namely,  dorsal  flexion  as  the  first  and  most  essential 
part  of  the  manoeuvre,  seems  to  have  met  with  more  general  approval 
than  any  other,  and  the  following  observations,  made  by  the  venerable 
Eeuben  D.  Mussey,  of  Cincinnati,  illustrate  the  general  practice  among 
American  surgeons  at  this  day. 

"  I  tilt  the  dislocated  phalanx  up  until  it  stands  upon  its  articu- 
lating end,  place  both  forefingers  so  as  to  hold  it  in  that  position,  and 
at  the  same  time  press  against  the  distal  extremity  of  the  metacarpal 
bone,  make  firm  pressure  with  the  thumbs  against  the  base  of  the 
dislocated  phalanx,  and  slide  it  into  its  place,  which  can  generally  be 
accomplished  with  ease. 

"  More  than  twenty-five  years  ago,  the  chairman  of  this  committee, 
from  attention  to  the  mechanism  of  the  raetacarpo-phalangeal  joint  of 
the  thumb,  convinced  himself  that  the  principal  impediment  to  the  re- 
duction of  the  first  phalanx  from  backward  displacement  is  the  short 
flexor  of  the  thumb,  between  the  two  portions  of  which  (lying  close 
together  where  they  are  fastened  to  the  sesamoid  bones)  the  head  of 
the  metacarpal  bone  has  been  thrust,  the  contracted  part  or  neck  of 
this  bone  lying  firmly  grasped  by  them.  Fifteen  years  ago,  a  case 
occurred  of  this  dislocation  which  he  could  not  reduce  in  the  ordi- 
nary way.  A  subcutaneous  division  of  one  of  the  heads  of  this  mus- 
cle was  made  with  an  iris  knife,  and  the  reduction  was  accomplished 
with  the  greatest  ease. 

"Last  year,  another  case  occurred  in  which  we  failed  of  reduction 
by  Dr.  Crosby's  method,  which  we  believe  to  be  the  best,  and  the  sub- 
cutaneous division  of  both  heads  of  the  muscle  was  made,  and  the  re- 
duction instantly  effected.  The  punctures  were  covered  with  collo- 
dion, and  the  thumb  supported  by  a  splint.  As  the  patient  was  in- 
temperate, entire  abstinence  from  liquor  and  the  adoption  of  a  light 
diet  were  enjoined.  Neither  pain  nor  inflammation  followed,  and  a 
month  afterwards  the  joint  had  free  motion.  After  the  intemperate 
and  irregular  habits  were  resumed,  the  joint  in  a  few  weeks  was  found 


612         OF    FIEST   PHALANGES    OF    THUMB    AND    FINGERS. 

anchylosed.  In  these  cases,  the  knife,  in  the  subcutaneous  operation, 
was  carried  down  to  the  metacarpal  bone,  so  far  behind  its  head  as  to 
preclude  the  possibility  of  mistaking  the  lateral  ligaments  for  the  mus- 
cles. These  ligaments  are  very  short  and  inserted  close  to  the  artic- 
ular surfaces,  and  are  probably,  one  or  both,  ruptured  in  this  disloca- 
tion."i 

Dr.  J.  P.  Batchelder,  of  Kew  York,  in  a  paper  read  before  the  New 
York  Medical  Association  in  1856,  says  :  "  The  surgeon  should  take  the 
metacarpal  portion  of  the  dislocated  thumb  between  the  thumb  and 
finger  of  one  hand,  and  flex  or  force  it  as  far  as  may  be  into  the  palm  of 
the  hand,  for  the  purpose  of  relaxing  the  muscles  connected  with  the 
proximal  end  of  the  phalanx,  particularly  the  flexor  brevis  pollicis. 
He  should  then  apply  the  end  of  the  thumb  of  this  hand  against  the 
displaced  extremity  of  the  dislocated  phalanx,  for  the  purpose  of  forc- 
ing it  downwards,  and  at  the  same  time  grasp  the  displaced  thumb 
with  his  other  hand,  and  move  it  forcibly  backwards  and  forwards,  as 
in  strongly  forced  flexion  and  extension,  the  pressure  against  the  upper 
extremity  of  the  first  phalanx  being  kept  up.  In  this  way  the  dislo- 
cated bone  may  be  made  to  descend,  so  as  to  be  almost  or  quite  on  a 
line  with  the  articulating  surface  of  the  metacarpal  bone,  when  the 
thumb  may  be  forcibly  flexed,  and,  if  it  be  not  reduced,  as  forcibly 
extended,  and  brought  backwards  to  a  right  angle  with  the  metacarpal 
bone,  when,  if  the  downward  pressure,  with  the  thumb  placed  as  before 
directed  for  that  purpose,  has  been  continued  (which  thumb,  by  main- 
taining its  position,  acts  as  a  fulcrum,  as  well  as  by  its  pressure),  the 
bone  will  slip  into  its  place,  and  the  reduction  be  effected  in  less  time 
than  has  been  spent  in  describing  the  process."^ 

Six  successful  cases  of  treatment  by  this  method  are  mentioned  in 
the  American  Journal  of  Medical  Sciences  for  April,  1858 ;  one  by 
Rickard,  one  by  Morgan,  two  by  Cutter,  and  two  by  Crosby. 

By  those  who  have  regarded  extension  as  an  important  element  in 
the  reduction,  various  instruments  have  been  devised  for  the  purpose 
of  obtaining  a  secure  hold  upon  the  dislocated  member.  Sir  Astley 
Cooper,  as  we  have  already  seen,  recommended  the  sailor's  clove  hitch;-'' 
Lawrie  advises  that  the  thumb  shall  be  thrust  into  the  open  handle  of 
a  large  door  key  ;■*  Charri^re  and  Luer,  of  Paris,  have  each  invented 
forceps,  so  constructed  with  fenestra  and  straps,  as  that  when  the  blades 
are  closed  'the  member  is  held  very  firmly  in  its  grasp.  Richard  J. 
Levis,  of  Philadelphia,  recommends  "  a  thin  strip  of  hard  wood,  about 
ten  inches  in  length,  and  one  inch,  or  rather  more,  in  width.  (Fig.  249.) 
One  end  of  the  piece  is  perforated  with  six  or  eight  holes.  The  oppo- 
site end  is  partly  cut  away,  forming  a  projecting  pin,  and  leaving  a 
shoulder  on  each  side  of  it.  Toward  this  end  of  the  strip,  a  sort  of 
handle  shape  is  given  to  it,  so  as  to  insure  a  secure  grasp  to  the  ope- 
rator. Two  pieces  of  strong  tape  or  other  material,  about  one  yard  in 
length,  are  prepared.     One  of  these  is  passed  through  the  holes  at  the 

1  Mussey,  Trans.  Amer.  Med.  Assoc,  vol.  iii.  1850,  p.  357. 

2  Batchelder,  New  York  Journ.  Med.,  May,  18.^6,  p.  340. 

^  Op.  cit.,  p.  561 ;  also  Bost.  Med.  and  Surg.  Journ.,  Oct.  1,  1857. 
*  Lawrie,  Am.  Journ.  Med.  Sci.,  vol.  xxii.  p.  229. 


FIRST  PHALANX  OF  THE  THUMB  BACKWARDS. 


613 


end  of  the  strip,  leaving  a  loop  on  one  side.     The  other  tape  is  passed 
through  another  pair  of  holes,  according  as  it  may  be  a  thumb  or  finger 


Fig.  249. 


Levis' s  instrument  for  reduction  of  dislocations  of  fingers  or  the  thumb. 

to  which  it  is  to  be  applied,  or  varied  to  suit  the  length  of  the  finger, 
leaving  a  similar  loop.  If  a  dislocated  thumb  is  to  be  acted  on,  the 
second  tapes  should  be  passed  through  the  holes  nearest  the  first.  The 
ends  of  each  separate  tape  are  then  tied  together. 

"  To  apply  this  apparatus,  the  finger  is  passed  through  the  loops.  (Fig. 
250).  The  loop  nearest  the  first  joint  is  then  tightened  by  drawing  on 
the  tape,  which  is  then  brought  along  the  strip  to  the  opposite  end, 
across  one  of  the  shoulders,  and  secured  by  winding  it  firmly  around 


Fig.  250. 


Levis' s  instrument  applied  to  the  first  finger. 

the  projecting  pin.  The  other  tape  is  tightened  in  a  like  manner,  cross- 
ing the  other  shoulder,  and  winding  around  the  pin  in  an  opposite 
direction,  when,  for  security,  the  ends  of  the  tapes  are  finally  tied  toge- 
ther."^ 

This  apparatus  enables  the  operator  to  apply  both  extension  and 
flexion  or  leverage  in  any  direction.  The  proximal  end  of  the  phalanx 
may  be  lifted,  or  even  rotated  so  as  to  allow  one  side  of  the  bone  to 
approach  the  socket  before  the  other. 

Malgaigne  describes  an  apparatus  invented  by  Kirchoff,  which  is 
very  similar  to,  yet  not  quite  so  complete,  as  this  of  Levis. 

In  the  April  number  of  the  Buffalo  Medical  Journal,  for  1847,  I 
have  described  an  instrument,  or  rather  a  toy,  in  my  possession, 
which  I  suggested  might  be  useful  for  the  purpose  of  making  exten- 
sion upon  dislocated  fingers ;  and  which,  as  will  be  seen  by  a  reference 
to  one  of  the  cases  already  reported  in  this  chapter,  I  have  since  ap- 
plied successfully.  It  is  made  by  the  Indians  in  this  vicinity,  and  may 
always  be  obtained  during  the  watering  season,  at  the  Indian  toy 

'  Levis,  Amer.  Journ.  Med.  Sci.,  Jan.  1857,  p.  62. 


614        OF    FIEST   PHALANGES    OF    THUMB    AND   FINGEES. 

shops  at  Niagara  Falls.  The  Indians  call  it  a  "  puzzle"  (Fig.  251), 
and  know  no  other  use  for  it  than  to  fasten  it  upon  the  thumb  or 
finger  of  some  victim,  and  then  pull  him  about  until  he  begs  to  be 
released. 

The  "puzzle"  is  an  elongated  cone  of  about  sixteen  or  eighteen 
inches  in  length,  made  of  ash  splittings,  and  braided ;  the  open  end 
of  the  cone  being  about  three-fourths  of  an  inch  in  diameter,  and  the 

Fig.  251. 


Indian  "puzzle,"  employed  for  the  reduction  of  dislocations  in  small  joints. 

opposite  end  terminating  in  a  braided  cord.  When  applied  to  the 
finger,  it  is  slipped  on  lightly,  forming  a  cap  to  the  extremity,  and  to 
half  the  length  of  the  finger,  but  on  traction  being  made  from  the  oppo- 
site end,  it  fastens  itself  to  the  limb  with  a  most  uncompromising 
grasp.  If  constructed  of  appropriate  size  and  of  suitable  materials,  it 
becomes  the  more  securely  fastened  in  proportion  as  the  extension  is 
increased ;  yet,  applying  itself  equally  to  all  the  surfaces,  it  inflicts 
the  least  possible  pain  and  injury  upon  the  limb.  When  we  wish  to 
remove  it,  we  have  only  to  cease  pulling,  and  it  drops  off'  spontane- 
ously. 

Dr.  Holmes  says  that  the  same  instrument  is  made  by  the  Indians 
of  Maine,  and  that  several  years  ago  Dr.  Davis,  of  Portland,  brought 
one  to  Boston,  and  showed  it  to  the  Society  for  Medical  Improvement, 
suggesting  that  it  might  be  used  in  the  same  manner  which  I  have 
recommended.^ 

Finally,  in  some  compound  dislocations  it  would  be  better  not  to 
attempt  the  reduction  of  the  dislocation  until  resection  has  been  prac- 
ticed. Samuel  Cooper  relates  a  case  in  which  the  reduction  was  fol- 
lowed by  inflammation  and  death  within  a  week  after  the  accident, 
and  Norris,  of  Philadelphia,  mentions  an  instance  which  came  under 
his  observation,  where  violent  inflammation  and  tetanus  followed  the 
reduction.^  Roux,  Evans,  Wardrop,  Gooch,  Sir  Astley  Cooper,  and 
many  other  surgeons,  have  practiced  resection  successfully  in  these 
accidents,  and  have  added  their  testimony  in  favor  of  this  mode  of  pro- 
cedure. 


§  2.  Dislocations  of  the  First  Phalanx  of  the  Thumb  forwards. 

Up  to  the  present  moment,  I  have  met  with  but  two  examples  of 
this  dislocation,  while  the  backward  dislocation  has  been  seen  by  me 
five  times. 


'  Trans.  Amer.  Med.  Assoc,  vol.  i.  p.  267. 
^  .K orris,  Amer.  Jo  urn.  Med.  Sci.,  vol.  xxxi. 


p.  16. 


FIEST    PHALAXX    OF    THE    THUilB    FOETVARDS.  615 

Horace  Kneeland,  of  Rochester,  X.  Y.,  set.  24,  dislocated  the  first 
phalanx  of  the  right  thumb  forwards,  by  striking  a  man  with  his 
clenched  fist ;  the  force  of  the  blow  being  received  upon  the  back  of 
the  second  joint  of  the  thumb.  The  dislocation  had  existed  three  days 
when  he  called  upon  me,  and  in  the  meanwhile  several  attempts  had 
been  made  to  reduce  the  bone  by  simple  extension.  The  first  pha- 
lanx was  in  front  of  the  metacarpal  bone,  and  in  the  same  plane ;  but 
the  last  phalanx  was  slightly  inclined  backwards.  The  hand  was 
already  swollen  and  quite  painful. 

Seizing  the  dislocated  thumb  in  the  palm  of  my  right  hand,  with 
my  fingers  resting  upon  the  back  of  the  patient's  hand,  I  forced  the 
two  phalanges  into  flexion  by  firm  and  steady  pressure  continued  for 
a  few  seconds,  when  suddenly  the  bones  resumed  their  places,  and  all 
deformity  disappeared. 

Intense  inflammation  resulted,  followed,  after  a  few  days,  by  suppu- 
ration under  the  palmar  fascia ;  and  in  the  end  the  thumb  was  almost 
completely  anchylosed.^ 

On  the  24th  of  April,  1855,  J.  M.  Booth,  of  Buffalo,  set.  19,  called 
at  my  of&ce,  having  a  dislocation  forwards  of  the  first  phalanx,  occa- 
sioned about  half  an  hour  before  by  being  thrown  from  a  horse.  The 
last  two  phalanges  were  neither  flexed  nor  extended,  but  straight,  and 
parallel  with  the  metacarpal  bone. 

By  the  same  manoeuvre  adopted  in  the  preceding  case,  but  with 
only  very  moderate  force,  the  dislocation  was  promptly  reduced. 

The  usual  causes  of  this  accident  are,  falls  or  blows  upon  the  thumb 
while  it  is  flexed ;  and  the  symptoms  which  characterize  it  are,  in 
general,  such  as  we  have  seen  in  the  two  examples  which  have  just 
been  given.  The  metacarpal  bone  projects  posteriorly,  and  the  first 
phalanx  produces  a  corresponding  projection  toward  the  palm  ;  the 
two  phalanges  are  extended  upon  each  other,  and  parallel  with  the 
metacarpal  bones.  N^laton  saw  a  case  in  which  the  first  phalanx  was 
flexed  about  45°  ;  and  in  several  examples  it  has  been  observed  to 
be  slightly  rotated  inwards. 

In  the  few  examples  of  this  accident  which  have  been  reported,  the 
reduction  was  easily  accomplished ;  or,  at  least,  we  may  say  that  the 
difficulties  in  the  way  of  reduction  were  not  so  great  as  they  are 
usually  found  to  be  in  dislocations  backwards.  Malgaigne  has  been 
able  to  collect  but  four  undoubted  examples,  all  of  which  were  re- 
duced ;  and  Lenoir  was  able  to  effect  the  reduction  by  moderate 
measures,  after  the  bone  had  been  dislocated  thirty-eight  days. 

Lombard,  after  the  trial  of  other  plans,  finally  succeeded  by  reversing 
the  phalanx.  Employing,  as  we  have  before  termed  it,  "dorsal  flex- 
ion," with  extension  and  lateral  motion ;  but  in  all,  or  nearly  all  the 
other  examples,  the  reduction  has  been  effected  by  flexing  the  thumb 
forcibly  toward  the  palm ;  the  reverse  of  the  method  which  we  have 
seen  preferred,  especially  by  American  surgeons,  in  dislocations  back- 
wards. My  own  experience  also  authorizes  me  to  recommend  this 
plan. 

'  Trans.  X.  Y.  State  Med.  Soc,  1855,  p.  73. 


616         OF    FIEST   PHALANGES    OF    THUMB    AND   FINGEES. 


§  3.  Dislocations  of  the  First  Phalanx  op  the  Fingers. 

The  index  and  little  fingers,  owing  to  their  exposed  situations,  are 
most  liable  to  these  dislocations.  I  have  met  with  two  examples  of 
traumatic  dislocations  of  these  joints,  one  of  which  was  a  forward,  and 
the  other  a  backward  luxation,  and  both  had  occurred  in  the  index 
finger. 

James  Nesbitt,  of  Buffalo,  set.  11,  dislocated  the  index  finger  of  the 
right  hand,  backwards,  by  a  fall  down  a  flight  of  stairs.  On  the  same 
day,  Feb,  11,  1851,  he  called  upon  me,  and  I  found  the  finger  neither 
flexed  nor  extended,  but  straight  and  immovable.  The  projections 
occasioned  by  the  ends  of  the  two  bones  were  very  marked,  and  such 
as  to  render  an  error  in  the  diagnosis  impossible.  Reduction  was 
accomplished  with  great  ease,  by  reversing  the  finger  and  employing 
moderate  extension,  while  at  the  same  time  the  proximal  extremity  of 
the  first  phalanx  was  pushed  toward  the  distal  end  of  the  metacarpal 
bone.  In  short,  the  process  was  the  same  as  that  which  we  have 
recom.mended  in  dislocations  of  the  thumb  backwards. 

Fig.  252. 


Backward  dislocation  of  first  phalanx.    Eeduction  by  extension. 

In  the  example  of  dislocation  forwards,  occasioned  by  a  blow  from 
a  hard  ball,  received  upon  the  end  of  the  finger,  the  first  phalanx  was 
in  a  position  of  extreme  extension,  and  the  second  moderately  flexed. 
Reduction  was  effected  with  great  ease  by  extension  in  a  straight  line. 
But  if  the  surgeon  were  to  experience  difficulty  in  the  reduction,  it 
would  no  doubt  be  advisable  to  resort  to  the  method  of  extreme 
flexion. 

In  one  instance,  I  have  seen  nearly  all  the  fingers  of  the  left  hand, 
and  the  thumb  of  the  right  dislocated  backwards,  by  the  contraction 
of  the  cicatrix  after  a  severe  burn. 


PHALANGES    OF   THE    THUMB   AND    FINGEES.  617 


CHAPTER    XV. 

DISLOCATIONS   OF  THE  SECOND  AND   THIED  PHA- 
LANGES  OF  THE  THUMB  AND   FINGEES. 

Notwithstanding  slight  differences  in  the  form  of  the  articulations 
between  the  thumb  and  fingers,  and  in  the  size  and  situation  of  the 
bones  which  compose  the  phalanges  of  the  fingers,  we  are  disposed, 
contrary  to  the  practice  of  some  other  writers  upon  this  subject,  to  con- 
sider all  the  dislocations  to  which  these  several  joints  are  liable,  under 
one  section.  Nor,  indeed,  after  the  attention  which  we  have  given  to 
the  dislocations  at  the  metacarpo-phalangeal  articulations,  do  we  find 
much  to  add  in  relation  to  these  accidents ;  since  in  almost  every  point 
of  view  in  which  they  may  be  considered,  they  have  so  much  in 
common. 

The  last  phalanx  of  the  thumb  is,  of  all  the  phalanges,  most  liable 
to  dislocation,  and  this  generally  takes  place  backwards.  Yery 
frequently,  also,  it  is  accompanied  with  such  a  laceration  as  to  render 
it  compound.  The  dislocated  phalanx  is  usually  reversed  in  the 
backward  dislocation,  and  straight,  or  nearly  so,  in  the  forward  dislo- 
cation. 

Keduction  may  be  accomplished  easily  by  forced  dorsal  flexion,  in 
the  case  of  the  backward  luxation,  and  by  forced  palmar  flexion,  in 
the  case  of  the  forward  dislocation. 

In  the  winter  of  1848,  a  young  man  was  brought  into  my  clinic, 
who  had  met  with  a  forward  subluxation  of  this  phalanx  about  one 
month  before.  He  had  fallen  upon  the  end  of  his  thumb,  and  as  the 
accident  was  followed  by  a  good  deal  of  inflammation  and  swelling, 
he  did  not  notice  the  displacement  until  some  time  afterwards.  The 
proximal  end  of  the  last  phalanx  projected  two  or  three  lines  toward 
the  palm ;  the  finger  was  straight,  and  this  joint  anchylosed.  I  did 
not  think  the  chance  of  restoring  and  maintaining  the  bone  in  position 
sufficient  to  warrant  any  interference,  and  he  was  dismissed  with  an 
assurance  that  after  a  few  months  it  would  occasion  him  no  great 
inconvenience. 

On  the  2d  of  March,  1851,  Thomas  Burton,  aged  about  twenty-two 
years,  by  a  fall  dislocated  the  second  phalanx  of  the  middle  finger  of 
the  right  hand,  backwards.  The  force  of  the  concussion  was  received 
upon  the  extremity  of  the  finger.  Nine  hours  after  the  accident  I 
found  the  bones  unreduced ;  the  finger  nearly  straight,  or  with  only 
slight  flexion  of  the  second  phalanx  upon  the  first ;  the  third  phalanx 
forcibly  straightened  upon  the  second;  all  the  joints  rigid;  finger  very 
painful  and  somewhat  swollen. 

By  moderate  extension  alone,  applied  for  a  few  seconds,  the  reduc- 
tion was  accomplished. 


618  PHALANGES    OF    THE    THUMB    AND    FINGEES. 

Fig.  253. 


Dislocation  of  the  second  phalanx  backwards. 

James  Cooper,  of  tbis  city,  set,  23,  came  to  me  on  Sunday  morning 
the  14th  of  Dec,  1851,  to  obtain  counsel  in  relation  to  his  finger 
which  had  been  dislocated  the  day  before,  but  which  he  had  himself 
reduced  by  simple  extension  made  in  a  straight  line.  His  own  ac- 
count of  it  was,  that  he  fell  upon  a  slippery  side-walk,  striking  upon 
the  end  of  his  ring  finger  in  such  a  way  that  it  seemed  to  double 
under  him.  On  examination,  he  found  the  second  bone  dislocated 
inwards,  or  to  the  ulnar  side,  completely,  the  end  of  the  first  phalanx 
forming  a  broad  projection  upon  the  opposite  side;  the  last  two 
phalanges  fell  over  toward  the  middle  finger,  but  they  were  neither 
flexed  nor  extended.  Seizing  upon  the  end  of  the  finger  with  his  right 
hand  and  pulling  forcibly,  he  promptly  reduced  the  dislocation  him- 
self. 

The  bones  were  now  completely  in  place,  but  the  joints  were 
swollen,  tender,  and  quite  stiff". 

In  Sept.,  1851,  by  the  politeness  of  Dr.  Briggs,  the  attending  sur- 
geon, I  was  permited  to  see  in  the  hospital  of  the  New  York  State 
Prison,  at  Auburn,  a  forward  dislocation  of  the  second  phalanx  of  the 
little  finger  of  the  left  hand,  unreduced.  This  man  was  at  the  date  of 
my  examination  forty-one  years  old,  and  the  dislocation  had  existed 
eighteen  years ;  having  been  occasioned  by  a  fall.  A  surgeon  in 
Greene  Co.,  IST.  Y.,  had  attempted  to  reduce  it  soon  after  the  disloca- 
tion occurred,  but  had  failed.  The  joint  was  nearly  anchylosed,  yet 
the  finger  was  quite  as  useful  for  all  ordinary  purposes  as  before. 

Fig.  254. 


Dislocation  of  the  second  phalanx  forwards. 

Dislocation  of  the  last  phalanx  is  frequently  occasioned  in  the 
game  of  base  ball,  by  the  ball  being  received  upon  the  extremity  of 
the  finger. 

A  young  man  who  was  studying  medicine,  and  a  private  pupil  of 
mine,  in  attempting  to  catch  a  very  hard  ball,  received  it  upon  the 
extremity  of  the  middle  finger  of  the  left  hand,  dislocating  the  last 
phalanx  forwards.     Twenty  minutes  after  the  accident,  I  found  the 


DISLOCATIONS    OF    THE    THIGH.  619 

distal  extremity  of  the  second  phalanx  projecting  backwards  through 
the  skin,  the  tendon  of  the  extensor  muscle  being  torn  completely  off 
from  its  point  of  attachment  to  the  last  phalanx.  The  last  phalanx 
was  in  a  position  of  slight  dorsal  flexion,  or  extreme  extension. 

Seizing  upon  the  extremity  of  the  finger,  I  attempted  to  reduce  the 
dislocation  by  direct  traction,  aided  by  pressure  upon  the  exposed  end 
of  the  second  phalanx,  but  I  was  unable  to  succeed  until  I  brought 
the  last  phalanx  into  a  position  of  palmar  flexion. 

A  slight  disposition  to  relaxation  was  manifested,  and  a  gutta- 
percha splint  was  therefore  applied;  and  to  prevent  inflammation, 
the  young  man  was  directed  to  keep  it  mioistened  with  cool  water 
lotions.  Only  a  moderate  amount  of  inflammation  followed,  and  in  a 
few  weeks  the  cure  was  complete. 

Such  accidents,  attended  with  laceration  of  the  integuments,  fre- 
quently demand  amputation,  or  at  least  resection  of  the  projecting 
bone,  but  we  think  Mr.  Miller  is  scarcely  right  when  he  says  that 
compound  dislocations  of  the  fingers  almost  always  are  of  such  severity 
as  to  demand  amputation. 


CHAPTER    XVI. 

DISLOCATIONS   OF  THE   THIGH   (C  OX  0-FEM  0  R  AL) . 

The  femur  is  especially  liable  to  dislocation  in  four  directions, 
namely,  upwards  and  backwards  upon  the  dorsum  ilii,  upwards  and 
backwards  into  the  ischiatic  notch,  downwards  and  forwards  into  the 
foramen  thyroideum,  and  upwards  and  forwards  upon  the  pubes. 

Dislocations  are  occasionally  met  with  which  cannot  be  arranged 
properly  under  either  of  these  divisions ;  indeed,  it  is  scarcely  necessary 
to  say  that  the  head  of  the  bone  may  be  thrown  in  almost  every  direc- 
tion from  its  socket,  upwards,  downwards,  inwards,  and  outwards,  or 
in  either  of  the  diagonals  between  these  lines ;  and  that  while  in  a  vast 
majority  of  cases,  it  will  assume  one  of  the  positions  first  named,  it 
may  in  a  few  exceptional  examples  fall  short  of,  or  much  exceed  the 
limits  assigned  in  this  division.  Thus,  we  shall  have  occasion  here- 
after to  mention  examples  of  dislocation  directly  upwards,  in  which 
the  head  of  the  bone  will  be  found  resting  upon  the  fossa  between  the 
upper  margin  of  the  acetabulum  and  the  anterior,  inferior  spinous  pro- 
cess of  the  ilium,  or  still  higher  between  the  anterior  superior  and 
the  anterior  inferior  spinous  processes,  or  a  little  to  the  one  side  or  to 
the  other  of  these  points.  Examples  will  be  shown  of  dislocations 
directly  downwards,  in  which  the  head  of  the  femur  will  rest  upon 
the  notch  between  the  lower  margin  of  the  acetabulum  and  the  tuber 


620  DISLOCATIONS    OF    THE    THIGH. 

ischii,  or  still  lower,  and  actually  below  the  tuberosity,  or  downwards 
and  backwards  below  the  spine  of  the  ischium,  into  the  lower  or  lesser 
sacro-sciatic  notch.  The  head  may  be  thrust  across  the  foramen  thy- 
roideum,  and  be  only  arrested  in  the  perineum  upon  the  ramus,  or 
even  beyond  the  ramus  of  the  ischium  and  pubes;  it  may  lodge  upon 
the  anterior  surface  of  the  body  of  the  pubes,  as  well  as  upon  its  supe- 
rior edge ;  and  finally,  it  may  rest  against  the  posterior  margin  of  the 
acetabulum  instead  of  rising  upon  the  dorsum,  or  it  may  only  mount 
upon  its  margin,  in  either  of  the  directions  named. 

In  regard  to  frequency,  the  four  principal  dislocations  occur  in  the 
order  in  which  we  have  mentioned  them ;  thus,  of  104  dislocations  of 
the  hip  which  I  have  taken  the  pains  to  collate,  excluding  the  anoma- 
lous or  extraordinary  dislocations,  and  which  my  intelligent  pupil, 
Mr.  Frank  Hodge,  has  carefully  analyzed,  55  were  upon  the  dorsum 
ilii,  28  into  the  great  ischiatic  notch,  13  upon  the  foramen  thyroideum, 
and  8  upon  the  pubes.  Chelius  and  Samuel  Cooper  have,  however, 
reversed  the  order  of  the  last  two  varieties,  arranging  dislocations  upon 
the  pubes,  in  the  order  of  frequency,  before  dislocations  into  the  fora- 
men thyroideum. 

Coxo-femoral  dislocations  may  occur  at  any  period  of  life;  one 
example  is  mentioned,  in  the  Gazette  Medicale^  of  a  recent  dislocation 
upon  the  dorsum  ilii,  in  a  child  eighteen  months  old.^  Mr.  Kirby  has 
reported,  in  the  Dublin  Medical  Press  for  October  26,  1842,  a  case  of 
recent  dislocation  in  the  same  direction,  in  a  child  of  three  years,^ 
and  Dr.  Buchanan  has  seen  another,  at  the  same  age,  in  a  little  girl; 
the  dislocation  being  into  the  ischiatic  notch.^  Mr.  Image  communi- 
cated to  the  Suffolk  branch  of  the  Provincial  Medical  and  Surgical 
Association,  the  case  of  a  boy,  three  and  a  half  years  old,  with  a  dislo- 
cation upon  the  dorsum  ilii.  It  had  existed  twelve  days  when  he  was 
admitted  to  the  Suffolk  Hospital  in  May,  1847.  Mr.  Image,  in  re- 
porting this  case  to  the  Society,  remarked  that  he  had  been  induced 
to  lay  it  before  them,  "  in  consequence  of  a  charge  having  been  urged 
against  a  neighljoring  surgeon,  of  pretending  to  reduce  a  dislocation 
of  the  femur  on  the  dorsum  ilii,  in  a  child  only  four  years  old,  that 
child  being  a  pauper,  and  chargeable  to  the  parish.  It  was  agreed 
and  proved  by  authorities  that  no  such  case  was  recorded,  and  there- 
fore had  not  occurred,  and  that  seven  years  old  was  the  earliest  period 
at  which  this  accident  had  taken  place."^ 

J.  M.  Litten,  of  Austin,  Texas,  reports  a  case  of  dislocation  upon 
the  dorsum  ilii,  in  a  girl  four  years  old,  which  he  reduced  by  mani- 
pulation.* 

Dr.  J.  C.  Warren,  of  Boston,  met  with  an  incomplete  dislocation 
toward  the  foramen  thyroideum,  in  a  child  six  years  old,  which, 
having  been  displaced  eight  or  ten  weeks,  he  was  unable  to  reduce.^ 

'  New  York  Journ.  Med.,  Nov.  1850,  p.  416. 

2  Amer.  Journ.  Med.  Sci,,  vol.  xxxi.  p.  207,  Jan.  1843. 

3  Lond.  Med.-Chir.  Rev.,  Dec.  1828,  p.  251. 
*  New  York  Journ.  Med.,  Sept.  1848,  p.  281. 
6  Ibid.,  March,  1852,  p.  259. 

^  Boston  Med.  and  Surg.  Journ.,  vol.  xxiv.  p.  220. 


UPWARDS   AND   BAGKWAEDS    ON    THE    DORSUM   ILII.      621 

Sir  Astley  Cooper  mentions  a  case  in  a  girl  seven  years  old.*  I  have 
myself  met  with  two  dislocations  upon  the  dorsum  ilii,  which  occurred 
at  ten  years,  and  one  into  the  foramen  thyroideum.^  Norris  reports  a 
case  at  eleven  years,^  and  Gibson  at  twelve/  On  the  other  hand, 
Gauthier  has  seen  a  dislocation  of  the  hip  in  a  woman  eighty-six 
years  of  age/  The  large  majority,  however,  occur  between  the 
fifteenth  and  forty-fifth  years  of  life.  From  an  analysis  of  eighty-four 
cases,  we  have  obtained  the  following  results : — 


Under  15 

years  . 

15  cases 

15  to  30 

a 

32     " 

30  to  45 

ii 

29     " 

45  to  60 

(I 

7    " 

60  to  85 

11 

1  case 

The  youngest  being  two  years  and  one  month,  the  oldest  sixty-two 
years,  and  the  average  being  a  fraction  less  than  thirty-four. 

They  are  much  more  frequent  in  men  than  in  women ;  owing,  pro- 
bably, to  the  greater  exposure  of  the  former  to  the  accidents  from 
which  these  dislocations  usually  result,  and  possibly,  also,  in  some 
measure,  to  certain  peculiarities  in  the  form  and  structure  of  the  neck 
of  the  femur  in  the  male.  Of  one  hundred  and  fifteen  cases  collected 
by  me,  one  hundred  and  four  were  in  males  and  eleven  in  females.  Dr. 
J.  K.  Eodgers,  of  New  York,  mentioned,  however,  at  a  meeting  of  the 
New  York  Kappa  Lambda  Society,  that  he  had  seen  and  reduced  four 
dislocations  of  the  femur  upon  the  dorsum  ilii  in  females,  and  that  a 
fifth  case  had  recently  come  to  his  knowledge  in  the  New  York  city 
hospital.^ 

Gibson  mentions  an  example  of  dislocation  of  both  thighs  at  the 
same  moment.'' 


§  1.  Dislocations  Upwards  and  Backwards  on  the  Dorsum  Ilii. 

Syn. — "Upwards  on  the  dorsum  ilii;"  Sir  A.  Cooper,  Miller,  Pirrie.  "  Upwards  and 
outwards  ;"  Boyer,  Dupuytren.  "  Upwards  and  backwards  upon  the  back  of  the  hip 
bone;"  Chelius.     "Iliac;"  Gerdy,  Vidal  (de  Cassis),  Malgaigne. 

Causes. — Generally  they  are  occasioned  by  some  violence  which 
forces  the  thigh  into  a  state  of  extreme  adduction,  or  of  adduction 
united  with  rotation  inwards;  and  especially  when  at  the  same  moment 
the  head  of  the  femur  is  driven  upwards  and  backwards.  Thus,  a  dis- 
location upon  the  dorsum  may  result  from  a  fall  from  a  height,  when 
the  force  of  the  concussion  is  received  upon  the  outside  of  the  knee ; 
the  thigh  being  thus  converted  into  a  lever  of  the  first  kind,  whose 
long  arm  is  outside  of  the  margin  of  the  acetabulum  ;  or  the  disloca- 

'  a.  Coop,  on  Disloc,  Amer.  ed.,  p.  83,  case  27. 

2  Buf.  Med.  Journ.,  vol.  viii.  p.  6.  Trans.  New  York  State  Med.  Soc,  1855.  My 
Report  on  Disloc. 

3  Amer.  Journ.  Med.  Sci.,  Feb.  1839,  p.  296.         *  Gibson's  Surg.,  vol.  i.  p.  389. 
^  Gauthier,  Malgaigne,  op.  cit.,p.  805. 

6  J.  K.  Rodgers,  New  York  Journ.  Med.,  July,  1839,  vol.  i.  First  ser.  p.  220. 
''  Gibson's  Surg.,  vol.  i.  p.  385.     Sixth  ed. 


622 


DISLOCATIONS    OF    THE    THIGH. 


tion  may  be  occasioned  by  a  fall  upon  the  foot  or  knee,  while  the  limb 
is  adducted,  by  which  the  head  of  the  femur  will  be  at  the  same  mo- 
ment driven  upwards  and  outwards  from  its  socket.  The  accident  is 
equally  liable  to  result  from  the  fall  of  a  heavy  weight,  such  as  a  mass  of 
earth,  upon  the  back  of  the  pelvis  when  the  body  is  much  bent  forwards. 
The  following  case  presents  an  extraordinary  example  of  this  form 
of  dislocation,  produced  by  a  force  acting  upon  the  thigh  as  a  lever  of 
the  first  kind. 

B.  ,of  Rochester,  N.  Y.,  set.  10,  fell,  in  Feb.  1841,  from  the  top  of  the 
high  bank  just  below  the  Genesee  Falls,  at  Rochester,  a  distance  of 
about  one  hundred  feet.  Before  he  reached  the  bottom  of  the  preci- 
pice, he  struck  upon  an  oblique  plane  of  ice,  from  which  he  slid  gradu- 
ally down  upon  the  surface  of  the  river,  which  was  then  completely 
frozen  over.  He  did  not  lose  his  consciousness  in  the  descent,  nor 
after  his  arrest  upon  the  river,  but  began  immediately  to  call  for  as- 
fc'istance.  He  remembers  very  well  that  when  he  struck  the  glacier,  the 
concussion  was  received  upon  the  right  side  of  the  right  knee,  and  a 
mark  of  contusion  at  this  point  confirmed  his  statement.  Dr.  Ellwood, 
of  Rochester,  assisted  by  myself,  reduced  the  dislocation  within  one 
hour  after  its  occurrence.  We  employed  pulleys,  but  the  reduction 
was  accomplished  easily  in  about  two  minutes,  and  without  the  appli- 
cation of  much  force;  the  bone  resuming  its  place  with  an  audible 
snap.     His  recovery  was  rapid  and  complete.* 

Pathological  Anatomy. — The  capsule  is  lacerated  more  or  less  ex- 
tensively, but  especially  in  its  posterior  half;  the  round  ligament  is 

ruptured ;  some  of  the  small  external 
rotator  muscles  are  generally  stretched 
or  torn  completely  asunder,  the  glutseus 
maximus,medi us,  and  minimus  are  pushed 
upwards  and  folded  upon  each  other,  the 
head  of  the  femur  resting  upon  or  within 
the  fibres  of  the  deeper  muscles ;  the  tri- 
ceps adductor  is  put  upon  the  stretch. 

Surgeons  have  not  been  agreed  as  to 
the  cause  of  the  great  difficulty  which 
has  usually  been  experienced  in  the  re- 
duction of  this  and  of  all  other  forms  of 
coxo-femoral  dislocations.  While  some 
have  ascribed  it  alone  to  the  resistance  of 
the  muscles,  others  have  with  equal  con- 
fidence, ascribed  the  opposition  to  an  en- 
tanglement of  the  head  and  neck  of  the 
bone  in  the  rent  capsule ;  and  still  others 
believe  that  the  impediment  ought  to  be 
looked  for  sometimes  in  the  muscles  and 
sometimes  in  the  capsule,  or  in  both  at 
the  same  moment. 

Sir  Astley  Cooper  thought  that  the  cap- 
sular ligament  was  generally  too  much  torn  to  ofl'er  any  impediment 


Fig.  255. 


Dislocation  upon  the  doi'sum  ilii. 


1  Trans.  New  York  State  Med.  Soc,  1855,  p.  76.    My  Report  on  Dislocations. 


UPWARDS    AND    BACKWAEDS    ON    THE    DORSUM    ILII.      623 

to  reduction,  and  he  refers  to  some  dissections  in  confirmation  of  this 
opinion.  Nathan  Smith  affirmed  that  the  chief  obstacle  to  reduction 
by  extension  was  to  be  found  in  the  resistance  offered  by  the  gluteii 
muscles,  which,  although  at  first  relaxed,  would  soon  become  tense 
under  the  stimulus  of  the  extension,  and  which,  in  order  that  the  bone 
might  resume  its  position,  must  actually  be  stretched  considerably  be- 
yond their  normal  length.  W.  W.  Eeid  declares  that  the  sole  resist- 
ance is  at  first  in  the  abductors  and  rotators,  but  that  finally  the  psoas 
magnus,  iliacus  internus,  and  triceps  adductor  become  tense  where  the 
pulleys  are  employed. 

Dr.  Fenner,  of  New  Orleans,  gives  the  particulars  of  a  dissection  of 
the  hip  of  a  man  admitted  into  the  Charity  Hospital,  who  died  from 
injuries  received  by  the  bursting  of  a  steamboat  boiler.  His  condi- 
tion being  considered  hopeless,  no  attempt  was  made  to  reduce  the 
dislocation.  The  limb  was  shortened  one  inch  and  a  half,  and  the  toes 
turned  inwards.  Extensive  ecchymosis  existed.  On  raising  the 
glutseus  maximus  and  medius,  the  naked  head  of  the  femur  was  found 
lying  on  the  dorsum  ilii  with  the  ligameutum  teres  hanging  to  it,  but 
partially  torn  off".  Portions  of  the  obturator  externus,  pyriformis,  and 
gemelli  were  ruptured  and  lacerated.  The  capsule  was  torn  through 
one-half  of  its  extent. 

Dr.  Fenner  now  proceeded  to  cut  away  the  muscles,  and  when  all 
the  external  muscles  about  the  joint  had  been  removed  the  thigh  could 
not  be  brought  down ;  the  iliacus  internus  and  psoas  magnus  were 
then  severed,  which  permitted  it  to  descend  a  little,  but  the  head  could 
not  be  replaced;  the  triceps  adductor  was  then  divided  without  effect. 
The  ilio-femoral  ligament  was  found  tensely  stretched.  All  the  mus- 
cles between  the  pelvis  and  the  thigh  were  then  severed,  and  still  it 
was  impossible  to  reduce  the  dislocation  ;  the  head  of  the  femur  could 
not  be  forced  back  through  the  rent  in  the  capsule  from  which  it  had 
escaped  ;  and  it  was  not  until  the  opening  was  enlarged  from  one-half 
to  three-quarters  of  an  inch,  that  the  reduction  was  accomplished. 

Dr.  Fenner  infers  that  the  capsule  possesses  sufficient  elasticity  to 
allow  the  smooth  head  of  the  femur  to  pass  out  through  a  lacerated 
opening  which  might  at  once  contract,  so  as  to  offer  considerable  resist- 
ance to  its  return,  and  that  occasionally  this  is  the  true  explanation  of 
the  difficulty  in  reduction.^  Dr.  Gunn,  of  Ann  Arbor,  Michigan,  after 
repeated  experiments  made  upon  the  dead  body,  conclades  that  the 
muscles  offer  no  impediment  whatever  to  the  reduction,  and  that  the 
"untorn  portion  of  the  capsular  ligament,  by  binding  down  the  head 
of  the  dislocated  bone,  prevents  its  ready  return  over  the  edge  of  the 
acetabulum  to  its  place  in  the  socket."^  Dr.  Moore,  of  Eochester,  who 
has  often  repeated  the  same  experiments  upon  the  cadaver,  declares 
also  that  in  attempting  to  reduce  the  femur  by  extension  alone  he  has 
constantly  observed  that  the  untorn  portion  of  the  capsule  offered  the 
main  resistance,  and  that  reduction  could  not  be  accomplished  until 
this  was  more  completely  broken  up  f  while  Markoe,  of  New  York, 

'  New  York  Joum.  Med.,  Sept.  1848,  p.  268  ;  from  New  Orleans  Med.  and  Surg.  Journ., 
July,  1848. 

2  Ibid.,  Nov.  1853,  p.  423  et  seq.  ^  Ibid.,  July,  1855,  p.  69. 


624 


DISLOCATIONS    OF    THE   THIGH. 


Fig.  256. 


attributes  tlie  resistance  to  both  the  muscles  and  the  capsule,  but 
chiefly  to  the  action  of  the  former,  especially  the  rotators.^ 

The  conclusion  to  which  we  ought  to  arrive  seems  to  be  that  in  some 
cases,  the  capsule  being  completely,  or  almost  completely  torn  away, 
the  muscles  offer  the  only  resistance ;  and  that  according  to  the  exact 
position  of  the  limb  or  degree  of  displacement,  one  or  another  set  of 
muscalar  fibres  will  oppose  the  reduction;  and  in  other  cases,  the 
muscles  being  paralyzed  by  the  shock,  or  by  ansesthetics,  the  partially 
torn  capsule,  into  which  the  head  of  the  bone  is  received  as  in  a  button- 
hole, prevents  its  free  return  into  its  socket. 

Symptoms. — Sir  Astley  Cooper  affirmed  that  the  limb  was  some- 
times found  shortened  in  this  dislocation,  to  the  extent  of  three  inches. 
Liston,  B.  Cooper,  Gibson,  and  others  repeat  the  affirmation.  Chelius 
places  the  extreme  of  shortening  at  two  and  a  half  inches.  Miller   at 

two  inches,  while  Malgaigne  de- 
clares that  he  has  never  seen  the  limb 
shortened  more  than  half  an  inch, 
and  that  in  some  cases  it  is  not 
shortened  at  all,  and  the  very  oppo- 
site opinions  entertained  by  other 
surgeons,  he  attributes  to  errors  in 
the  measurement.  I  am  certain, 
however,  that  Malgaigne  has  fallen 
into  some  error,  and  that,  while 
the  average  shortening  is  about  one 
inch  or  one  inch  and  a  half,  it  does 
occasionally  reach  three  inches. 

The  thigh  is  rotated  inwards,  ad- 
ducted  and  slightly  flexed  upon  the 
pelvis.  The  great  toe  of  the  dis- 
located limb,  when  the  patient  stands 
erect  (and  in  this  position  the  ex- 
amination ought  if  possible  to  be 
made),  rests  upon  the  instep  of  the 
foot  of  the  sound  limb,  and  the  knee 
touches  the  opposite  thigh  near  the 
upper  margin  of  the  patella.  It 
must  not  be  supposed,  however,  that 
the  position  of  the  limb  is  in  all 
cases  precisely  such  as  we  have  de- 
scribed. Indeed  the  degree  of  ro- 
tation, adduction,  flexion  &c.,  will 
vary  according  as  the  head  of  the 
femur  is  more  or  less  displaced,  the 
capsule  more  or  less  torn,  or  as  it 
may  be  torn  in  its  upper  or  lower 
Dislocation  upon  the  dorsum  iiii.  margins,  as  the  muscles  may  be  ac- 


'  New  York  Journal  Med.,  Jan.  1855. 


UPWARDS   AND    BACKWARDS    ON   THE    DORSUM    ILII.      625 

tually  rent  asunder  or  only  put  upon  the  stretch,  and  perhaps  also  ac- 
cording to  the  amount  of  injury  and  consequent  relaxation  which  they 
may  have  sustamed  from  the  shock.  The  thigh  can  be  easily  flexed  • 
adduction  is  more  diflScult,  but  abduction  is  almost  impossible,  except 
to  a  very  limited  extent:  the  body  of  the  patient  is  a  little  bent  for- 
wards: the  roundness  of  the  hip  is  lost  in  consequence  of  the  relaxa- 
tion of  the  gluten  muscles;  the  trochanter  major  is  depressed,  and 
approaches  the  anterior  superior  spinous  process  of  the  ilium,  and  if  the 
patient  IS  not  fat,  and  swelling  has  not  already  taken  place,  the  head 
of  the  femur  may  be  felt  in  its  new  position  rotating  under  the  hand 
when  the  limb  is  turned  inwards  or  outwards,  but  especially  may  it  be 
felt  when  by  flexing  or  extending  the  limb,  the  head  is  made  to  move 
downwards  and  upwards,  upon  the  dorsum  ilii. 

As  we  have  already  said,  this  examination  ought  to  be  made  if 
possible,  in  the  erect  posture ;  after  which,  it  will  be  well  to  place  the 
patient  alternately  upon  his  back,  upon  his  sound  side,  and  upon  his 
belly,  until  the  diagnosis  is  rendered  complete. 

The  differential  diagnosis  between  dislocation  upon  the  dorsum  ilii 
and  a  fracture  of  the  neck  of  the  femur  may  be  briefly  stated  as  follows. 
In  fracture,  we  may  expect  to  find  crepitus ;  the  limb  is  in  most  cases 
mobile  ;  the  toes  are  generally  turned  out ;  the  limb  is  shortened  mode- 
rately or  not  at  all;  the  patient  is  sometimes  able  to  walk  for  a  short 
distance ;  fractures  of  the  neck  of  the  femur  generally  occur  in  ad- 
vanced life. 

In  dislocation,  crepitus  is  not  often  present,  and  only  when  a  frac- 
ture coexists;  the  limb  is  immobile,  or  nearly  so;  the  toes  are  turned 
m;  the  limb  is  shortened  more;    the  patient  is  unable  to  bear  the 
weight  of  his  body  upon  his  foot  for  one  moment.   Skey,  however,  says 
he  has  seen  a  patient  with  a  recent  dislocation,  who  walked  one-quar- 
ter of  a  mile,  to  the  hospital.     I  do  not  think  any  other  similar  case  is 
upon  record.   Dislocations  of  the  femur  generally  occur  in  middle  life. 
I  have  been  frequently  told  by  persons  who  have  called  upon  me 
with  children  suffering  under  hip-disease,  that  they  had  been  informed 
the  hip  was  out,  and  they  expected  me  to  reduce  it.     In  two  or  three 
instances  they  have  blamed  their  surgeons  very  much,  because  they 
had  not  detected  the  accident  at  the  time  of  its  occurrence.     Norris,  of 
Philadelphia,  mentions  an  extraordinary  example  of  this  kind, 'as 
having  been  presented  at  the  Pennsylvania  Hospital,  and  which  ought 
to  serve  as  a  sufficient  warning  to  prevent  similar  mistakes  in  future. 
A  lad,  twelve  years  old,  was  brought  to  the  hospital  from  a  neighbor- 
ing State,  who  a  short  time  previous  had  been  suddenly  attacked  with 
lameness  in  his  right  limb,  and  which,  by  his  friends  was  attributed 
to  some  injury  received  in  play.   Two  physicians,  who  had  been  called 
to  see  the  boy,  pronounced  him  to  be  laboring  under  dislocation  of 
:the  hip,  and  had  made  two  strong  efforts  with  the  pulleys,  to  reduce  it; 
.but  after  causing  great  suffering  they  gave  up  all  hopes  of  ever  re- 
placing the  bone,  and  sent  him  to  Philadelphia.     The  symptoms  were 
plainly  those  of  hip-joint  disease  in  its  early  stage.     The  attitude  was 
that  assumed  by  those  laboring  under  this  affection ;  the  leg  seemed 
lengthened,  but  a  eareful  measurement  showed  that  it  was  of  the  same 
40 


626  DISLOCATIONS    OF    THE   THIGH* 

length  with  the  other ;  the  buttock  was  flattened  and  the  motions  of 
the  joint  tolerably  free  but  painful.^ 

If  the  supposed  dislocation  occurs  in  a  child,  or  in  a  person  under 
ten  years  of  age,  we  ought  to  take  especial  pains  to  ascertain  that  it  is 
not  a  separation  of  the  epiphysis,  of  which  accident  we  have  men- 
tioned some  examples  when  speaking  of  fractures  of  the  neck  of  the 
femur. 

Prognosis. — Boyer  says  the  limb  remains  always  weaker  than  the 
other,  the  round  ligament  never  uniting  completely;  and  that  inflam- 
mation of  the  cartilages  and  synovial  glands  may  ensue,  ending  in 
caries  of  the  joint.  Such  results  have,  indeed,  been  occasionally  met 
with,  nor  are  examples  wanting  in  which  more  rapid  inflammation, 
resulting  in  the  formation  of  acute  abscesses,  has  followed,  but  these 
are  only  rare  accidents.  In  the  large  majority  of  cases  the  patients 
recover  speedily,  and  in  the  course  of  a  few  weeks,  or  months  at  most, 
the  limb  seems  to  be  as  sound  and  as  useful  as  before. 

Examples  of  non-reduction,  however,  from  an  error  of  diagnosis,  or 
what  is  more  pertinent  to  our  present  purpose,  from  a  failure  to 
accomplish  the  reduction  where  the  attempt  has  been  made,  are 
numerous.  Fortunately,  Mr.  Chelius,  the  author  of  a  most  excellent 
"■System  of  Surgery,^''  to  which  we  have  already  had  frequent  occasion 
to  refer,  has  sufficient  reputation,  the  world  over,  to  enable  him  to 
bear  a  portion  of  these  failures,  without  injury  to  himself  or  to  the 
profession  which  he  so  eminently  adorns.  We  shall  therefore  make 
no  apology  for  reporting  the  following  unsuccessful  attempt  to  reduce 
a  dislocation  of  the  hip  in  which  Mr.  Chelius  himself  was  the  operator. 

On  the  11th  of  June,  1851,  John  Mauren,  a  German,  set.  19,  called 
at  my  office  and  related  as  follows:  "When  ten  years  old,  I  fell  from 
a  tree,  a  height  of  six  feet,  and  dislocated  my  left  hip.  I  was  then 
living  twelve  miles  from  Heidelberg,  and  I  was  immediately  taken 
there,  but  I  did  not  see  Mr.  Chelius  until  the  next  morning.  He  took 
me  to  the  University,  and  before  the  medical  class  attempted  to  reduce 
it,  but  he  could  not.  During  several  weeks  following,  he  tried  six 
times,  using  pulleys,  &c.,  but  he  could  never  succeed." 

On  examination  I  found  the  limb  shortened  two  inches,  the  head  of: 
the  femur  lying  upon  the  dorsum  ilii ;  the  knee  was  turned  in,  but 
the  toes  were  inclined  a  little  outwards.     He  was  able  to  walk  rapidly, 
of  course  with  a  manifest  halt,  yet  without  pain  and  discomfort. 

Treatment. — Eegarding  dislocations  of  the  femur  upon  the  dorsum: 
ilii  as  the  type  of  all  the  coxo-femoral  dislocations,  the  remarks  which : 
we  shall  make  under  this  section  may  be  considered  applicable  with 
only  certain  qualifications  to  all  the  others. 

We  shall  arrange  the  various  methods  of  reduction  which  have; 
been  employed  by  surgeons  under  two  principal  heads,  namely,  mani- 
pulation and  extension.  It  is  not  possible,  however,  to  classify  rigidly 
the  different  procedures,  so  as  to  bring  them  under  these  two  simple 
divisions  without  some  violence;  since  neither  manipulation  nor  ex-, 

'  Norris,  Amer.  Journ.  Med.  Sci.,  vol.  xxv.  p.  280. 


UPWAEDS    AND    BACKWARDS    ON    THE    DORSUM    ILII.      627 

tension  has  usually  been  employed  alone,  but  almost  always  some 
degree  of  extension  has  been  recommended  in  connection  with  the 
manipulation;  if  not  in  the  first  instance,  at  least  in  the  event  of  the 
failure  of  mampulation  alone;  while,  on  the  other  hand,  extension  is 
seldom  if  ever  practiced  without  manipulation.  We  intend  then  to 
imply  by  these  designations  respectively,  that  either  manipulation  or 
extension  has  constituted  the  prevailing  feature  in  the  treatment 

Keduction  by  manipulation  dates  from  the  earliest  records  of  our 
science.  _  bays  Hippocrates:  "In  some  the  thigh  is  reduced  with  no 
preparation,  with  slight  extension  directed  by  the  hands,  and  with 
slight  movement;  and  in  some  the  reduction  is  efiected  by  bendino- 
the  limb  at  the  joint,  and  making  rotation."^  ° 

Eichard  Wiseman,  who  wrote  in  1676,  speaks  as  follows-  "If  the 
thigh-bone  be  luxated  inwards,  and  the  patient  young  and  of  a  tender 
constitution,  it  may  be  reduced  by  the  hand  of  the  chirurgeon  viz  •  he 
must  lay  one  hand  on  the  thigh,  and  the  other  on  the  patient's  le<^  and 
having  somewhat  extended  it  toward  the  sound  leg,  he  must  suddenly 
force  the  knee  up  toward  the  belly,  and  press  back  the  head  of  the 
lemur  into  its  acetabulum,  and  it  will  knap  in.  For  there  is  no  need 
of  so  great  extension  in  this  kind  of  luxation;  for  the  most  consider- 
able muscles  being  upon  the  stretch,  the  bowing  of  the  knee  as  afore- 
said reduceth  it;  yet  m  rough  bodies  it  may  require  stronger  exten- 
sion. ^  ° 

Eichard  Boulton  repeated,  in  1713,  almost  the  same  instructions 
aftirmmg  that  this  plan  was  applicable  especially  to  dislocations  in- 
wards, m  the  case  of  "young  and  tender  children."^ 
_  In  1742  Daniel  Turner  declared  that  he  had  reduced  three  disloca- 
tions of  the  hip,  one  of  which  was  a  backward  dislocation,  by  a  method 
combining  extension  with  manipulation,  but  alone  "by  the  strength  of 
the  arm  or  without  any  other  instrument."  Extension  and  counter- 
extension  being  made  by  assistants,  and  "as  soon  as  the  suro-eon  per- 
ceives the  bone  moving  out,"  says  Turner,  "let  him  take  hTs  oppor- 
tunity,  g-ivmg  order  to  the  extenders  below  suddenly  to  lift  up  the 
patient's  thigh  toward  his  belly,  pressing  with  his  hands,  either  to  the 
right  or  left,  as  the  situation  of  the  same  requires,  and  therewith  force 
back  Its  head  toward  the  acetabulum,  whereunto  it  will,  flipping  over 
the  tip  of  the  cartilage,  snap  sometimes  with  a  loud  noise."" 

Thomas  Anderson,  surgeon  of  Leith,  in  Scotland,  was  called,  in 
bept.  1772,  to  see  a  man  who  had  dislocated  his  left  femur  into  the 
foramen  thyroideum.  When  he  arrived  four  other  surgeons  were 
present,  and  prepared  to  use  the  pulleys,  which  they  did  in  his  pre- 
sence several  times,  but  to  no  purpose.  After  examining  the  limb 
carefully,  "  I  was  convinced,"  says  Mr.  Anderson,  "  that  attempting  the 
reduction  m  the  common  method,  with  the  thigh  extended,  was'  im- 

'  Works  of  Hippocrates,  Syd.  ed.,  vol.  ii.  p.  643. 
Eight  CMrurgical  Treatises.  By  Richard  Wiseman,  Serjeant-Chinirgeon  to  Kin^r 
Charles  II.  London,  1676.  Book  vii.  chap.  viii.  ° 

'of.^-^^^®"^  °^  Rational  and  Practical  Surgery.  By  Richard  Bovlton.  London,  1713 
p.  o4o.  '  ' 

*  The  Art  of  Surgery,  by  Daniel  Turner,  London,  1742,  vol.  ii.  p.  339. 


628  DISLOCATIONS    OF    THE    THIGH. 

proper,  as  the  muscles  were  all  put  on  the  stretch,  the  action  of  which 
is,  perhaps,  sufficient  to  overbalance  any  extension  we  can  apply.  But 
by  bringing  the  thigh  to  near  a  right  angle  with  the  trunk,  by  which 
the  muscles  would  be  greatly  relaxed,  I  imagined  that  the  reduction 
might  more  readily  take  place,  and  with  much  less  extension. 

"  When  I  made  this  examination,  he  was  lying  on  a  table  on  his 
back.  I  raised  the  thigh  to  about  a  right  angle  with  the  trunk,  and, 
with  my  right  hand  at  the  ham,  laid  hold  of  the  thigh,  and  made  what 
extension  I  could.  From  this  trial  I  found  I  could  dislodge  the  head 
of  the  bone.  At  the  same  time  that  I  did  this,  with  my  left  hand  at 
the  head  and  inside  of  the  thigh,  I  pressed  it  toward  the  acetabulum, 
while  my  right  gave  the  femur  a  little  circular  turn,  so  as  to  bring  the 
rotula  inwards  to  its  natural  situation;  and,  on  the  second  attempt,  it 
went  in  with  a  snap  observable  to  the  gentlemen  standing  around,  but 
more  so  to  the  poor  man,  who  instantly  cried  out  he  was  well  and  free 
from  paiu.  His  knees  could  then  be  brought  together;  the  legs  were 
of  the  same  length,  and  the  foot  in  its  natural  situation.  The  knees 
were  kept  together  for  some  time,  with  a  roller,  to  confine  the  motion 
of  the  thigh ;  and  in  three  weeks  he  was  at  his  work,  without  the  least 
stiffness  in  the  joint." 

Subsequently  Mr.  Anderson  reduced  by  a  similar  method  a  disloca- 
tion upon  the  dorsum  ilii  in  a  child  eight  years  old,  and  which  had 
been  out  nineteen  days.^ 

Says  Pouteau,  in  a  memoir  on  dislocations  of  the  thigh  upwards 
and  outwards:  "  We  observe  then,  first,  that  the  thigh  ought  to  be  flexed 
to  a  right  angle  with  the  body  during  the  extension  and  counter- 
extension;  second,  that  we  ought  to  rotate  the  thigh  from  within  out- 
wards, when  the  extension  appears  to  be  sufficient ;  third,  that  this 
position  puts  into  relaxation,  as  much  as  possible,  the  triceps  and 
gluteal  muscles  which  oppose  the  chief  resistance  to  the  extension, 
thus  saving  the  patient  from  excessive  pain ;  fourth,  that  the  flexion 
of  the  thigh  places  the  head  of  the  bone  in  the  best  position  for  a  re- 
turn to  the  cotyloid  cavity  during  extension;  fifth,  that  feeble  exten- 
sion suffices  for  the  reduction,  because  all  of  the  muscles  of  the  thigh 
are  relaxed."^ 

On  the  7th  of  Jan.  1811,  Dr.  Philip  Syng  Physick,  of  Philadelphia, 
reduced  an  outward  dislocation  of  the  hip,  after  extension  had  failed, 
by  flexing  the  thigh  to  a  right  angle  with  the  body,  and  then  giving 
to  the  limb  "  an  outward  circular  sweep.^ 

So  early  as  1815,  and  perhaps  much  earlier,  Nathan  Smith,  Prof,  of 
Surgery  in  the  New  Haven  Medical  College,  taught  that  the  only  cor- 
rect mode  of  reducing  a  dislocation  upon  the  ilium  was  to  flex  the  leg 
upon  the  thigh,  the  thigh  upon  the  pelvis,  and  then  to  carry  the  limb 
diagonally  to  the  opposite  side,  from  whence  it  was  to  be  brought  out- 
wards and  downwards ;''  and  in  1824,  Dr.  Smith,  being  under  oath, 

'  Anderson.     Medical  Commentaries,  Edinburgh,  1776,  vol.  ii.  pp.  261-4. 
^  Vidal  (de  Cassis)  ;  from  (Euvres  posthumes  de  Pouteau,  Paris,  1783. 
3  Physick,  Dorsey's  Surg.,  1813,  vi.  p.  242.     Mem.  of  Nathan  Smith,  1831,  p.  172. 
Phelps'  paper,  in  Trans.  New  York  State  Med.  Soc,  1856,  p.  169. 
*  Trans.  N.  Y.  St.  Med.  Soc,  1854,  p.  55. 


UPWAEDS   AND    BACKWARDS    ON   THE    DORSUM    ILII.      629 

affirmed  as  follows:  "I  do  not  think  tliat  the  mechanical  powers,  such 
as  the  wheel  and  axle,  or  the  pulleys,  are  necessary  to  reduce  a  dis- 
located hip,  or  any  other  dislocation."  He  further  adds  that  he  once 
reduced  a  dislocation  upon  the  dorsum  ilii  after  he  had  pulled  in  every 
direction  but  the  right,  "  by  carrying  the  knee  toward  the  patient's 
face,"^  Subsequently  the  son  of  Dr.  Smith,  Nathan  R,  Smith,  the 
present  distinguished  teacher  of  surgery  in  the  medical  college  at 
Baltimore,  gave  a  more  full  account  of  his  father's  method,  illustrating 
his  views  of  the  pathology  of  these  dislocations,  and  the  mechanism 
of  their  reduction  by  several  drawings.  It  must  be  noticed,  however, 
that  Dr.  Nathan  Smith  left  no  written  explanation  of  his  views  and 
practice,  except  that  which  is  to  be  found  in  the  affidavit  already  quoted, 
and  that  the  account  published  by  his  son  is  from  memory,  and  it  is 
given  as  follows :  "  The  patient  being  prepared  for  the  operation  by 
whatever  means  may  be  deemed  necessary,  may  be  placed  in  an  atti- 
tude convenient  for  the  operation,  with  the  body  securely  fixed,  by 
placing  him  in  the  horizontal  posture,  on  a  narrow  table  covered  with 
blankets,  and  on  the  sound  side.  To  the  table  his  body  should  be 
firmly  fixed,  and  this  can  be  conveniently  done  by  folding  a  sheet 
several  times,  lengthways — then  applying  the  middle  of  the  broad 
band  thus  made  to  the  inner  aod  upper  part  of  the  sound  thigh — 
carrying  its  extremities  under  the  table,  crossing  them  beneath  it,  and 
then  carrying  them  obliquely  up  and  crossing  them  firmly  over  the 
trunk,  above  the  injured  hip.  The  ends  may  then  be  secured  beneath 
the  table.  To  support  the  trunk  the  more  firmly,  a  pillow  may  be 
placed  on  each  side  of  it  upon  the  table,  and  be  included  in  the  band- 
age. Should  the  operator  design  to  employ  any  degree  of  extension, 
a  counter-extending  band  may  be  placed  in  the  perineum,  and  carried 
up  to  the  extremity  of  the  table,  be  fixed  to  some  more  firm  body,  or 
held  by  the  hands  of  assistants. 

"  The  operator  now  standing  on  the  side  to  which  the  patient's  back 
presents,  grasps  the  knee  of  the  dislocated  member  with  his  right 
hand  (if  the  left  femur  be  dislocated — vice  versa,  if  the  right),  and  the 
ankle  with  the  left.  The  first  effort  which  he  makes  is  to  flex  the  leg 
upon  the  thigh,  in  order  to  make  the  leg  a  lever  with  which  he  may 
operate  on  the  thigh-bone.  The  next  movement  is  a  gentle  rotation 
of  the  thigh  outwards,  by  inclining  the  foot  toward  the  ground,  and 
rotating  the  knee  outwards.  Next  the  thigh  is  to  be  slightly  abducted 
by  pressing  the  knee  directly  outwards.  Lastly,  the  surgeon  freely 
flexes  the  thigh  upon  the  pelvis  by  thrusting  the  knee  upwards  to- 
ward the  face  of  the  patient,  and  at  the  same  moment  the  ahduciion  is  to 
be  increased. 

"  Professor  N.  Smith  regarded  the  free  flexion  of  the  thigh  upon 
the  pelvis  as  a  very  important  part  of  the  compound  movement.  He 
believed  that  it  threw  the  head  of  the  bone  downwards,  behind  the 
acetabulum,  where  the  margin  of  the  cup  is  less  prominent,  and  over 
which,  therefore,  the  adductor  muscles  would  drag  it  with  less  diffi- 
culty into  its  place. 

I  Report  of  the  Trial  of  an  Action  for  Malpractice.  Lowell  v.  Faxon  and  Hawks, 
Machias,  Maine,  1824;  also  Buf.  Med.  Journ.,  vol.  xiii.  p.  515. 


630  DISLOCATIONS    OF    THE    THIGH. 

"  The  operator  may  slightly  vary  these  movements,  as  he  increases 
them,  so  as  to  give  some  degree  of  rocking  motion  to  the  head  of  the 
OS  femoris,  which  will  thereby  be  disengaged  with  the  more  facility 
from  its  confined  situation  among  the  muscles."^ 

Fig.  257. 


H'athan  Smith's  metliod  of  reduction  hy  manipulation.  (From  Smith's  "  Memoirs.") 

Dr.  Luke  Howe,  of  Boston,  who  was  a  pupil  of  Nathan  Smith's, 
gives  the  following  account  of  the  method  practiced  by  him  success- 
fully, about  the  year  1820,  and  which  method  he  says,  was  recom- 
mended by  his  preceptor :  "  The  patient  was  permitted  to  lie  on  his 
back  on  the  bed  where  I  found  him,  the  knee  of  the  luxated  limb 
turned  in  and  over  the  other.  I  raised  the  knee  in  the  direction  it 
inclined  to  take,  which  was  toward  the  breast  of  the  opposite  side, 
till  the  descent  of  the  head  of  the  bone  gave  an  inclination  of  the 
knee  outwards,  when  I  made  use  of  the  leg,  being  at  right  angle  with 
the  thigh,  as  a  lever  to  rotate  the  latter  and  turn  the  head  of  it  in- 
wards. It  then  readily  returned  to  its  socket,  with  an  audible  snap. 
During  this  operation,  the  two  assistants  who  had  been  placed  to 
make  the  lateral  extension  and  counter-extension,  if  ultimately  re- 
quired, were  directed  to  draw  moderately  at  their  towels.  How  much 
of  the  success  of  the  operation  is  to  be  imputed  to  their  extension,  and 
the  rotation  of  the  thigh  by  the  leg,  I  am  unable  to  determine ;  but  as 
Dr.  Snaith  succeeded  without  the  aid  of  either,  and  as  the  head  of  the 

'  Medical  and  Surgical  Memoirs,  by  Nathan  Smith,  late  Prof,  of  Surgery,  &c.,  in  Yale 
College.  Edited  bv  Nathan  R.  Smith,  Prof,  of  Surgery  in  Univ.  of  Maryland.  Balti- 
more, 1831,  pp.  163-182. 


UPWAEDS    AND    BACKWAEDS    ON"    THE    DOESUM    ILII.      631 

femur  seemed  to  descend  by  an  easy  and  natural  process,  I  am  inclined 
to  believe  that  all  that  is  necessary  in  such  cases,  is  to  elevate  the 
knee,  when  the  ilium,  the  muscles  attached  to  it,  and  perhaps  the 
ligaments,  become  the  natural  fulcrum,  over  which  the  thigh,  as  a 
lever,  acts  to  bring  the  head  down  and  inwards  into  the  socket."^ 

Kluge,  in  1825,  combined  moderate  extension  with  manipulation, 
by  flexing  both  the  leg  and  thigh,  while  at  the  same  moment  the 
thigh  was  abducted  and  the  knee  rotated  inwards,^  Wathman,  in 
1826,  directed  that  in  this  dislocation  the  limb  should  be  seized  by 
the  knee  and  ankle  and  slowly  lifted  forwards  until  it  came  to  a  right 
angle  with  the  long  axis  of  the  body ;  when,  if  the  outward  "  self- 
twisting  of  the  thigh"  occurs,  "  which  cannot  be  prevented  by  fast 
holding,"  the  movement  of  the  head  of  the  bone  is  declared,  and  it 
will  only  remain  for  the  surgeon  to  let  down  the  thigh  gradually 
upon  the  bed  so  that  the  two  limbs  will  come  side  by  side,  and  the 
reduction  will  be  accomplished.^ 

Rust  recommended  also,  in  1826,  a  similar  plan,  combining  mode- 
rate extension  by  the  hands,  with  flexion  and  abduction  of  the  thigh.^ 

Colombat,  whose  opinions  date  from  1830,  suggested  that  the 
patient  should  lay  himself  forwards  upon  a  bed  or  a  table  no  higher 
than  his  hips,  with  the  sound  leg  and  foot  resting  upon  the  floor,  and 
that  then  the  surgeon  seizing  the  foot  with  one  hand,  so  as  to  flex  the 
leg,  should,  with  the  other  hand,  exercise  a  moderate  degree  of  exten- 
sion, and  at  the  same  time  move  the  limb  to  the  right  or  to  the  left, 
backwards  and  forwards,  in  order  to  disengage  the  head  of  the  femur ; 
and,  finally,  that  he  should  communicate  to  the  thigh  a  sudden  move- 
ment of  circular  rotation,  either  from  within  outwards,  or  from  with- 
out inwards,  as  the  surgeon  might  choose/ 

Collin  states  that,  in  1833,  he  had  reduced  four  dislocations  of  the 
hip  by  a  method  very  similar  to  this  recommended  by  Colombat.^ 

Dr.  William  Ingalls,  of  Chelsea,  Mass.,  reduced  a  compound  dis- 
location of  the  femur,  in  which  the  head  of  the  bone  rested  upon  the 
pubes,  after  an  unsuccessful  attempt  had  been  made  to  reduce  it  by 
extension.  "An  assistant,  taking  the  ankle  of  the  dislocated  limb 
in  his  right  hand,  and  placing  his  left  in  the  ham,  bent  the  leg  at  right 
angles  upon  the  thigh,  and  the  thigh  upon  the  pelvis,  then  lifting  with 
a  power  little  more  than  sufficient  to  elevate  the  whole  limb,  he  car- 
ried it  to  its  greatest  state  of  abduction,  at  the  same  time  rotating  the 
femur  inwards  while  Dr.  Ingalls  passed  his  thumb  through  the  wound, 
and  pressing  upon  the  head  of  the  femur,  directed  it  toward  the  ace- 
tabulum. At  this  moment  he  directed  the  limb  to  be  forced  toward  its 
fellow,  by  which  the  reduction  was  efi'ected  with  the  greatest  possible 
ease  and  elegance."^ 

Similar  methods  of  reduction,  with  only  such  slight  variations  as 
scarcely  deserve  a  special  notice,  have  been  suggested  and  practiced 

'  Howe,  Boston  Med.  and  Surg.  Journ.,  vol.  xxii.  p.  249,  May,  1840. 

2  Chelius's  Surg.,  hj  South,  Amer.  ed.,  vol.  ii.  p.  241.  ^  Ibid.,  p.  240. 

*  Ibid.,  p.  241,  note  by  South.  ^  Malgaigne,  op.  cit.,  vol.  ii.  p.  825. 

^  Malgaigne,  op.  cit.,  p.  823. 

'  Ingalls,  Bransby  Cooper's  ed.  of  Sir  Astley's  English  ed  ,  1842,  and  Amer.  ed.,  1852. 


632 


DISLOCATIOJSrS    OF    THE    THIGH. 


from  time  to  time  bj  Palletta,  in  1818;'  Desprez,  in  1835  ;2  Yial  in 
1841  f  Fischer,  Mahr,  and  Clarke,  in  1849." 

In  1851,  Dr.  W.  W.  Eeid,  of  Eochester,  N.  Y.,  published  an  account 
of  the  method  practiced  by  himself  successfully  in  three  cases  of  dis- 
location upon  the  dorsum  ilii,  the  first  of  which  dated  from  the  year 
1844.  His  method,  as  applied  to  a  dislocation  upon  the  dorsum  ilii, 
consists  in  "flexing  the  leg  upon  the  thigh,  carrying  the  thigh  over 
the  sound  one,  upwards  over  the  pelvis  as  high  as  the  umbilicus,  and 
then  abducting  and  rotating  it."* 

Dr.  Markoe,  of  New  York,  adopts  the  same  procedure,  except  that 
when  thelimb  has  been  sufficiently  flexed  and  abducted,  he  directs 
that  the  limb  shall  be  gradually  brought  down,  and  he  affirms  that  it 
IS  during  this  last  manoeuvre  that  he  has  usually  found  the  bone 
resume  its  place  in  the  socket.^ 

Reduction  by  extension  dates  from  a  period  equally  early  with  re- 
duction by  manipulation.  Hippocrates  recommended,  when  other  and 
gentler  means  had  failed,  to  make  extension  and  counter-extension  ; 
the  extending  bands  being  made  fast  above  the  knee  and  above  the 
ankle,  so  as  to  distribute  the  points  of  pressure;  and  the  counter-ex- 
tending bands  being  secured  around  the  chest  under  the  arm.pits,  and 
also,  if  thought  necessary,  in  the  perineum  of  the  sound  side. 

Fig.  258. 


Hippocrates's  mode  of  reducing  dislocations  of  the  hip  by  extension. 

Among  the  methods  recommended  and  practiced  by  Hippocrates, 
was  sitting  across  the  upper  round  of  a  ladder  with  a  weight  attached 
to  the  thigh  of  the  dislocated  limb;  or  suspending  the  patient  from  a 
sort  of  gallows  with  the  head  downwards,  and  if  the  weight  of  the 
patient's  own  body  proved  insufficient,  the  surgeon  might  add  his  also; 
a  method  which  Hippocrates  characterizes  as  "a  good,  proper,  and 
natural  mode  of  reduction,  and  one  which  has  something  of  display  in 
it,  if  any  one  takes  delight  in  such  ostentatious  modes  of  procedure."^ 


'  Chelius's  Surg. ;  note  by  South.  2  Malgaigne. 

^  Dublin  Med.  Press,  Dec.  3,  1851.     New  York  Journ.  Med.,  March,  1852. 

5  Reid,  Buf.  Med.  Journ.,  vol.  vii.,  August,  1851,  pp.  129-143. 

^  Markoe,  New  York  Journ.  Med.,  Jan.  1855. 

'  Works  of  Hippocrates,  >"yd.  ed.,  London,  vol.  ii.  p.  641. 


Ibid. 


UPWARDS    AND    BACKWARDS    ON"    THE    DORSUM    ILII.      633 

With  various  modifications  as  to  the  position  of  the  limb,  and  as  to 
the  points  upon  which  the  extending  and  counter-extending  forces  are 
to  be  applied,  and  with  differently  constructed  appliances,  surgeons 
have  continued  to  employ  extension  down  to  this  day. 

The  great  majority  have  regarded  flexion  of  the  thigh  as  essential 
to  success ;  some  holding  the  limb  only  slightly  flexed,  and  others  in- 
sisting that  the  flexion  should  be  increased  to  a  right  angle  with  the 
body. 

The  French  surgeons,  including  Boyer  and  Yidal  (de  Cassis),  prefer 
generally  to  apply  the  extending  bands  to  the  feet,  in  order  that  the 
muscles  of  the  thigh  may  not  be  stimulated  to  contraction  by  the  pres- 
sure of  the  bandages.     Mr.  Skcy  adopts  the  same  method. 

Sir  Astley  Cooper,  Samuel  Cooper,  B.  Cooper,  Fergusson,  Miller, 
Pirrie,  Erichsen,  and  the  English  surgeons  generally,. make  fast  the 
lacq  above  the  knee.  J.  L.  Petit  and  Duverney,  among  the  French, 
and  Dorsey,  Gibson,  with  most  of  the  American  surgeons,  recommend 
the  same,  but  Gerdy  seeks  to  multiply  the  points  of  application,  and 
for  this  purpose  secures  the  extending  band  to  the  whole  length  of  the 
leg,  and  to  a  small  portion  of  the  thigh  above  the  knee. 

The  counter-extending  bands  are  now  almost  universally  made  to 
operate  against  the  perineum  of  the  dislocated  limb,  but  Roux,  follow- 
ing the  practice  of  Hippocrates,  places  it  in  the  perineum  of  the  sound 
limb.     Gibson  recommends  the  same  practice. 

Lizars  recommends  that  sometimes  the  reduction  should  be  attempted 
by  simply  placing  the  heel  in  the  perineum  and  making  the  exten- 
sion with  the  hands,  very  much  as  Sir  Astley  Cooper  advises  us  to 
proceed  in  dislocations  of  the  humerus.  Morgan  and  Cock,  of  Guy's 
Hospital,  have  reduced  six  cases  of  dislocation  of  the  hip-joint  by 
placing  the  foot  between  the  thighs,  so  that  it  pressed  against  the 
upper  part  of  the  dislocated  bone,  and  thrust  it  away  from  the  pelvis ; 
extension  and  rotation  of  the  limb  being  made  at  the  same  time  by 
assistants.*  Three  of  these  were  examples  of  dislocation  upon  the 
dorsum  ilii,  two  upon  the  pubes,  and  one  into  the  foramen  thyroideum  ; 
and  most  of  them  had  occurred  in  weak  or  elderly  persons. 

Ambrose  Pare  was  among  the  first  to  recommend  the  use  of  pulleys 
for  the  reduction  of  dislocations.  Most  surgeons  since  his  day  have 
employed  them  for  the  purpose  of  making  the  extension  more  energetic 
and  steady,  and  that  it  might  be  longer  continued.  Sir  Astley 
Cooper's  plan  of  procedure  is  as  follows  : — 

The  patient  having  been  bled  freely  and  the  muscles  still  farther 
relaxed  by  nauseating  doses  of  antimony  and  by  the  hot  bath,  he  is  to 
be  placed  on  his  back  upon  a  table  of  convenient  height  between  two 
staples;  a  strong  padded  leathern  girth  or  perineal  band,  constructed 
so  as  to  receive  the  thigh  and  to  press  at  the  same  moment  against  the 
perineum  and  the  outer  surface  of  the  pelvis,  is  then  applied  and  made 
fast  to  one  of  the  staples  situated  behind  the  patient  in  the  direction  of 
the  axis  of  the  limb.  A  wetted  linen  roller  is  next  to  be  tightly  applied 
just  above  the  knee,  and  upon  this  a  leathern  strap  is  to  be  buckled, 

'  Cock  and  Morgan,  Chelius,  op.  cit.,  vol.  ii.  p.  242,  note  by  South. 


634 


DISLOCATIONS    OF    THE    THIGH. 


having  two  short  straps  with  rings  at  right  angles  with  the  circular 
part ;  or  instead  of  this,  a  round  towel  made  in  the  knot  called  the 
clove-hitch.  The  knee  is  to  be  slightly  bent,  but  not  quite  to  a  right 
angle,  and  brought  across  the  opposite  thigh  a  little  above  the  knee. 
The  pulleys  being  now  attached,  the  extension  is  to  be  commenced. 

Fig.  259. 


Eeduction  of  a  dislocation  on  the  dorsum  ilii,  by  pulleys. 

A  very  simple  and  efficient  mode  of  making  the  extension,  if  one 
has  not  the  pulleys,  is  to  employ  for  this  purpose  a  small  rope,  the 
ends  being  tied  together  and  the  rope  being  then  doubled  upon  itself 
once  or  twice,  so  as  to  make  four  or  eight  parallel  cords.  The  oppo- 
site ends  of  this  bundle  of  ropes  being  made  fast  to  the  limb  and  the 
staple,  the  extension  is  made  by  thrusting  a  stick  through  its  centre 

Fig.  260.    , 


Reduction  of  a  dislocation  on  tlie  dorsum  ilii,  by  the  Spanish  windlass.     (Gilbert.) 

and  twisting  it.    To  avoid  twisting  the  limb,  that  end  of  the  rope  which 
is  attached  to  the  patient  may  play  in  a  swivel. 

I  have  several  times  had  occasion  to  resort  to  this  plan ;  and  indeed 


UPWAEDS    AND    BACKWAEDS    ON"    THE    DOESUM    ILII.      635 

it  has  been  for  some  time  known  and  practiced  among  surgeons  in  this 
country/  having  been  first,  according  to  Prof.  Gilbert,  introduced  by 
Fahnestock,  of  Pittsburg,  Pa. 

Jarvis's  adjuster,  to  which  I  have  already  made  allusion  when  speak- 
ing of  dislocations  of  the  humerus,  has  been  often  used  with  success  in 
dislocations  of  the  hip  as  well  as  in  dislocations  of  the  shoulder.^  Its 
power  is  equal  to  that  of  the  pulleys,  while  the  direction  of  the  force 
can  be  varied  with  much  greater  ease.  The  most  serious  objections 
to  the  instrument  as  employed  for  the  reduction  of  dislocations,  are  its 
complexity  and  its  expensiveness. 


Fig.  261. 


Jarvis's  adjuster:  applied  for  reduction  of  a  dislocation  of  the  hip. 

Mr.  Fergusson  says  that  the  Lancet  for  July  26,  1845,  contains  a 
description  of  a  similar  apparatus  constructed  by  Coxeter  at  the 
suggestion  of  Gr.  N.  Epps;^  and  L'Estrange,  of  Dublin,  has  invented 
a  "windlass"  for  making  extension,  with  a  "forceps"  by  which  the 
extending  power  can  be  instantly  disengaged.''  Mr.  Bloxham's  "dis- 
location tourniquet"  is  also  very  simple,  and  Mr,  Erichsen  affirms 
that  by  it  "any  amount  of  extending  force  that  may  be  required  can  be 
readily  set  up  and  maintained."^  Sedillot,  a  French  surgeon,  has  sug- 
gested that  when  pulleys  are  used,  we  should  measure  the  exact  power 
employed  in  the  reduction,  by  an  ingeniously  contrived  apparatus 

'  Gilbert,  of  Philadelphia.  Note  to  Pirrie's  Surg.;  also  Am.  Journ.  Med.  Sci.,  vol. 
XXXV.  April,  1845. 

2  Crandall,  Bost.  Med.  and  Surg.  .Tourn.,  vol.  xxxix.  p.  77;  Atlee,  Trans.  Amer.  Med. 
Assoc,  vol.  iii.  1850,  p.  357. 

*  Fergusson,  4th  Amer.  ed.,  p.  200.  *  Ibid.,  p.  198. 

*  Erichsen,  Amer.  ed.,  1859,  p.  242. 


636 


DISLOCATIONS    OF    THE    THIGH. 


called  the  dynamometer.'  Such  an  instrument  might  occasionally  be 
useful  in  preventing  the  application  of  excessive  force,  especially  when 
the  patient  is  under  the  influence  of  an  angesthetic. 


Fig.  262. 


Bloxham's  "dislocation  tourniquet,"  applied  for  reduction  of  a  dislocation  on  the  pubes. 


Finally,  without  attempting  to  determine  the  precise  relative  value 
of  these  different  procedures,  all  of  which  claim  for  themselves  the 
testimony  of  experience,  we  are  prepared  to  admit  that  no  one  of  them 
is  without  merit,  and  that  each  may  in  certain  cases  possess  advantages 
over  the  others.  Precisely  what  the  cases  are  to  which  each  individual 
method  may  be  especially  applicable,  we  believe  it  would  be  impossi- 
ble to  declare  unless  the  cases  were  actually  before  us;  and  even  then 
it  would  probably  be  found  difficult  to  say  which  was  the  best  until 
a  fair_  trial  of  one  or  more,  and  a  final  success,  had  determined  the 
question.  The  time  has  not  yet  arrived  in  which  we  may  institute  a 
rigid  comparison  between  the  relative  merits  of  the  two  leading  plans 
of  reduction,  manipulation,  and  extension,  for  while  it  is  true  ?hat  re- 
duction by  manipulation  has  been  practiced  from  the  earliest  day,  it 
is  equally  true  that  extension  has  been  generally  preferred  and  prac- 
ticed by  surgeons  in  all  ages,  and  especially  since  Sir  Astley  Cooper 
gave  his  admirable  instructions  upon  the  method  of  applying  extension 
and  counter-extension.  Indeed  it  was  not  until  Dr.  Reid,  of  Rochester, 
again  called  the  attention  of  the  profession  to  this  subject,  illustrating 
his  views  by  the  results  of  several  successful  experiments  and  by  in°- 
genious  arguments,  that  reduction  by  manipulation  could  be  said  to 
have  been  fairly  introduced  as  an  established  method  of  practice;  a 
large  majority  of  all  the  cases  upon  record  of  reduction  by  manipu- 
lation having  been  reported  since  the  year  1851,  the  period  of  Dr. 
Reid's  first  communication  to  the  Buffalo  Medical  Journal. 

_  The  following  summary  of  a  paper  prepared  by  myself,  with  the 
view  of  determining,  if  possible,  the  relative  value  of  the  two  methods, 
and  exhibiting  an  analysis  of  sixty-four  cases  in  which  manipulation 
was  employed,  will  enable  the  reader  to  form  some  estimate  of  the 
difficulty  in  which  this  subject  is  involved  ;  and  if  it  does  not  actually 

1  Amer.  Journ.  Med.  Sci.,  vol.  xv.  p.  530. 


UPWAEDS    AND    BACKWARDS    ON"    THE    DOESUM    ILII.      637 

decide  a  moot-point,  it  will  at  least  demonstrate  that  the  method  by 
manipulation  is  not  without  its  hazards.' 

Of  forty-one  cases  in  which  the  fact  is  stated,  twenty-eight  were 
reduced  on  the  first  attempt,  seven  on  the  second,  four  on  the  third,  and 
two  on  the  seventh.  In  seven  examples  the  head  of  the  femur  has 
been  thrown  from  one  position  to  another  upon  the  pelvis,  travelling 
from  the  dorsum  of  the  ilium  to  the  ischiatic  notch,  and  from  thence 
to  the  foramen  ovale ;  or  directly  from  the  dorsum  to  the  foramen,  and 
back  again  ;  or  in  other  directions,  according  to  the  character  of  the 
original  dislocation ;  in  some  instances  these  changes  being  made  as 
often  as  seven  times  in  succession.  In  the  majority  of  cases  no  evil 
consequences  seem  to  have  followed  upon  these  changes  of  position. 
One  of  my  own  cases  will  especially  serve  to  show  with  what  impunity 
sometimes  these  changes  may  be  made. 

John  Caswell,  get.  28,  was  admitted  to  the  Buffalo  Hospital  of  the 
Sisters  of  Charity  on  the  18th  of  January,  1858,  with  a  dislocation  of 
the  left  femur  upon  the  dorsum  ilii,  which  had  occurred  six  days 
before.  His  own  account  of  the  accident  was  that  he  was  standing  at 
the  bottom  of  a  well,  bent  forwards  until  his  body  was  at  a  right  angle 
with  his  thighs,  when  a  bucket  holding  five  hundred  pounds  of  earth  fell 
upon  his  back  and  hips.  No  attempt  had  been  made  to  reduce  the 
dislocation.  Five  times  in  succession  manipulation  made  by  myself 
failed,  leaving  the  head  of  the  bone  each  time  upon  the  dorsum  ilii; 
the  sixth  attempt,  made  with  the  addition  of  moderate  extension  by 
the  hands,  threw  the  head  into  the  foramen  thyroideum.  By  revers- 
ing the  movements,  it  was  easily  replaced  upon  the  dorsum  ilii.  The 
seventh  trial  was  made  in  the  same  manner,  except  that  when  I  sup- 
posed the  head  of  the  bone  to  be  opposite  the  lower  margin  of  the 
socket  I  did  not  permit  the  limb  to  turn  either  outwards  or  inwards, 
but  while  lifting  at  the  knee  with  my  hands,  with  sufficient  power  to 
raise  his  hips  from  the  table,  I  brought  the  limb  down  gradually  to  a 
line  parallel  with  the  opposite,  and  thus  finally  the  reduction  was 
accomplished.  No  pain  or  inflammation  followed,  and  in  two  weeks 
he  left  the  hospital ;  but  whether  he  was  able  to  walk  or  not  at  that 
time,  I  am  unable  to  say.^ 

In  Markoe's  paper,  published  in  the  New  York  Journal  for  January, 
1855,  several  similar  cases  are  reported,  in  which  the  results  have 
been  equally  fortunate ;  but  the  case  mentioned  as  having  been  under 
the  care  of  Dr.  Post,  of  the  New  York  Hospital,  had  a  more  serious 
termination.  This  patient,  John  Kelly,  set.  21,  had  a  dislocation  into 
the  ischiatic  notch,  and  on  the  same  day  the  reduction  was  attempted 
by  manipulation.  On  the  first  trial  the  head  of  the  bone  was  thrown 
into  the  foramen  ovale ;  and,  after  having  been  moved  backwards  and 
forwards  between  these  two  points  several  times,  it  was  finally  carried 
directly  from  the  foramen  ovale  into  the  socket  by  manual  extension 
applied  in  the  ordinary  way,  but  without  pulleys.    "In  this  case,"  says 

'  Reduction  of  Dislocation  of  the  Femur  by  Manipulation.  By  the  Author.  BuflFalo 
Medical  Journal,  Nov.  1857 ;  Feb.,  March,  June,  1859.  With  tables  constructed  by 
my  very  intelligent  pupil,  Lucien  Damainville. 

"  Buffalo  Medical  Journal,  vol.  xiii.  p.  682. 


638  DISLOCATION'S    OF    THE   THIGH. 

Markoe,  "the  cure  was  very  slow,  and  he  left  the  hospital  with  some 
degree  of  pain  and  swelling  about  the  joint.  I  learned  that  an  abscess 
formed  in  or  about  the  joint,  which  was  opened,  and  when  I  saw  him, 
a  year  after,  there  was  every  appearance  of  seated  morbus  coxarius.'' 
In  Case  14,  of  Markoe's  paper,  the  thigh  was  broken  at  the  neck 
after  manipulation  had  been  employed,  but  while  extension  was  being 
made  by  the  hands,  united  with  "  a  lifting  outwards."  Whether  the 
fracture  was  due  to  the  extension,  or  to  the  manipulation,  seems  not 
to  be  clearly  determined.  The  dislocation  had  existed  seven  weeks 
when  this  attempt  at  reduction  was  made. 

So  far  as  I  am  able  to  say,  these  are  all  the  examples  in  which  a  serious 
injury  has  been,  with  any  propriety,  charged  to  the  manipulation. 

Assisted  by  my  pupil,  Mr.  Hodge,  I  have  also  succeeded  in  collect- 
ing sixty-two  cases  of  attempts  at  reduction  by  extension ;  a  great 
majority  of  which,  we  find,  were  reduced  in  the  first  trials;  but  five 
cases  of  recent  dislocation  were  not  reduced  until  after  several  attempts 
had  been  made. 

In  five  cases  the  femur  was  broken.  The  first  occurred  in  St. 
Thomas's  Hospital,  London.  Ben.  Whittenburg,  set.  40,  was  admitted 
Nov.  4,  1827,  with  a  dislocation  into  the  ischiatic  notch,  of  twenty-two 
weeks'  duration.  After  bleeding,  &c.,  had  been  practiced,  an  attempt 
was  made  to  reduce  the  bone  by  pulleys,  in  which  the  reporter  pro- 
fesses to  believe  they  were  successful,  but  on  the  following  day  it  was 
plainly  enough  not  in  place.  Mr.  Travers  again  resorted  to  extension, 
and  while  extension  was  kept  up  and  the  assistants  were  rotating  the 
limb  outwards,  the  neck  of  the  femur  gave  way.^  Malgaigne  mentions 
a  case  in  which,  while  he  was  himself  directing  the  operation,  the  thigh 
was  broken  through  its  lower  third.  He  was  attempting  to  reduce  the 
bone  by  extension,  but  it  was  not  until  he  gave  the  signal  for  rotation 
outwards,  that  the  bone  gave  way.^  Gibson  says  that  Dr.  Physick,  at 
the  Pennsylvania  Hospital,  while  engaged  in  reducing  a  dislocated 
thigh  by  the  pulleys,  broke  the  femur  in  consequence  of  exerting  too 
much  force  upon  it  in  a  lateral  direction  by  an  additional  pulley ;  and 
that  a  similar  accident  is  supposed  to  have  happened  to  Drs.  Harris 
and  Randolph  in  the  same  hospital,  in  the  year  1838,  while  using  the 
pulleys  upon  a  boy  twelve  years  of  age ;  for  during  extension  and 
counter-extension,  at  the  moment  of  rotating  the  limb,  and  of  drawing 
it  forcibly  outwards  by  a  towel,  a  sudden  crack  was  heard.^ 

The  fifth  case  is  related  by  Sir  Astley  Cooper,  as  having  occurred 
at  the  Brighton  Hospital,  under  the  care  of  Mr.  Gwynue ;  the  dislo- 
cation was  upon  the  dorsum  ilii,  and  was  supposed  to  have  existed 
about  one  month.  The  neck  of  the  femur  was  broken  in  the  first  at- 
tempt at  reduction,  and  while  the  surgeon  was  making  extension,  with 
gentle  rotation.^ 

Sir  Astley  says,  "There  are  plenty  of  cases  upon  record,  of  fatal  ab- 
scesses from  violent  attempts  at  the  reduction  of  dislocated  hips."    We 

'  London  Med.-Chir.  Rev.,  Nov.  1828,  p.  239. 

2  Malgaigne,  op.  cit.,  voL  ii.  pp.  146  and  830. 

'  Gibson's  Surgery,  sixth  ed.,  voL  i.  p.  389. 

*  Sir  Astley  Cooper  on  Disloc,  &c.,  Amer.  ed.,  p.  88. 


UPWAEDS    AKD    BACKWARDS    ON   THE    DORSUM    ILII.      639 

presume  that  this  remark  has  reference  to  attempts  at  reduction  bj  ex- 
tension, since  in  his  day,  this  was  almost  the  only  mode  in  use  among 
surgeons.  He  adds,  moreover,  that  Mr.  Skey  has  mentioned,  in  the  Zan- 
cet,^  a  fatal  case  of  phlebitis  following  protracted  extension  of  the  hip. 

Malgaigne  has  collected  no  less  than  eight  similar  examples,  with 
several  more  in  which  serious  consequences  and  even  death  followed 
promptly  upon  violent  attempts  at  reduction  by  mechanical  means.^ 

The  head  of  the  bone  has  been  repeatedly  thrown  from  the  dorsum 
ilii  into  the  ischiatic  notch,  and  B.  Cooper  mentions  a  case  in  which 
the  bone  was  carried  from  the  foramen  ovale  into  the  ischiatic  notch, 
from  which  latter  position  it  could  not  afterwards  be  changed.^ 

As  to  the  relative  chances  of  failure  by  the  two  methods,  the  testi- 
mony of  the  recorded  cases  is  equally  unsatisfactory.  Of  the  failures 
by  extension,  the  experience  of  almost  every  surgeon,  the  journals  and 
the  treatises  furnish  a  sufficient  number  of  examples;  while  among  the 
sixty-four  cases  of  attempts  at  reduction  by  manipulation  collected  by 
me,  and  excepting  the  cases  in  which  the  bone  was  broken,  only  two 
were  positive  failures.  It  is  somewhat  remarkable,  however,  that  these 
two  cases  occurred  in  the  experience  of  the  New  York  City  Hospital; 
and  that  they  are  taken  from  a  total  of  fifteen,  this  being  the  whole 
number  which  had  been  treated  by  this  method  at  the  date  of  these 
observations,  in  the  New  York  Hospital.  One  had  existed  one  month, 
and  after  repeated  trials  by  manipulation  and  frequent  changes  of  posi- 
tion, it  was  finally  reduced  by  pulleys.  The  other,  a  dislocation  into 
the  ischiatic  notch,  had  existed  only  a  few  hours.  At  least  seven  or 
eight  trials  were  made  to  accomplish  the  reduction  by  manipulation, 
but  without  success.  The  first  attempt  by  extension  failed  also,  but 
in  the  second  attempt  the  femur  was  kept  at  a  right  angle  with  the 
body,  and  the  bone  was  soon  brought  into  its  socket.^ 

We  have  in  these  two  examples,  not  only  a  record  of  failure  by 
manipulation,  but  an  equal  record  of  success  by  extension ;  while,  on 
the  other  hand,  we  find  in  an  analysis  of  the  sixty-four  cases,  sixteen 
triumphs  of  manipulation  over  extension. 

We  must  not  omit  to  say,  in  order  that  the  reader  may  form  a  just 
estimate  of  the  value  of  these  statistics,  that  the  great  majority,  espe- 
cially of  the  cases  treated  by  manipulation,  have  occurred  in  private 
practice,  and  it  is  unnecessary  to  say  that  such  statistics  do  not  furnish 
the  most  reliable  basis  for  conclusions.  As  a  general  rule,  unsuccess- 
ful cases  are  not  published  by  private  practitioners,  but  successful 
cases  are  pretty  certain  to  be  made  known ;  while,  on  the  other  hand, 
a  series  of  cases  furnished  by  any  single  hospital  will  generally  be 
found  to  have  given  both  unsuccessful  and  successful  cases.  The 
writer  has  heard  lately  of  a  complete  failure  to  reduce  by  manipula- 
tion in  a  recent  luxation  of  the  hip,  after  repeated  efforts  on  several 
successive  days,  and  where  skilful  surgeons  were  in  attendance ;  but 
it  is  believed  that  no  account  of  the  result  has  been  published. 

'  Op.  cit.,  vol.  i.  p.  767,  1840-41.     Cooper  on  Disloc,  p.  69. 

2  Malgaigne,  op.  cit.,  vol.  ii.  p.  164  et  seq. 

3  Sir  Astley  Cooper  on  Disloc.     By  Bransby  Cooper,  Amer.  ed.,  p.  96. 
•*  Van  Buren,  New  York  Med.  Times,  Jan.  1856,  p.  126. 


6i0  DISLOCATIONS    OF    THE    THIGH. 

^  We  have  already  called  attention  to  the  fact,  that  in  the  New  York 
City  Hospital,  two  of  the  fifteen  cases  reported  were  failures ;  a  circum- 
stance of  remarkable  significance,  especially  when  we  consider  the  skill 
of  the  several  gentlemen  who  were  the  operators  in  these  cases ;  and  it 
plamly  renders  a  new  series  of  statistics  necessary,  drawn  solely  from 
the  experience  of  one  or  more  similar  large  establishments,  before  we 
shall  be  prepared  to  decide  positively  upon  the  relative  value  of  the 
two  procedures. 

Nevertheless,  we  shall  not  hesitate  to  express  our  present  convictions 
upon  this  subject,  reserving  to  ourselves  the  right  of  a  change  of 
opinion  whenever  the  proofs  shall  warrant  it. 

Manipulation,  owing  to  the  great  power  which  may  be  brought  to 
bear  upon  the  neck  and  head  of  the  bone  through  the  action  of  the 
shaft  of  the  femur  as  a  lever,  is  most  liable  to  throw  the  head  of  the 
bone  into  new  positions,  and  consequently  most  liable  to  rupture  the 
various  soft  tissues  about  the  joint,  to  produce  inflammation,  suppura- 
tion, and  caries.     For  the  same  reason  it  is  most  liable,  also,  to  fracture 
the  neck  of  the  femur.     It  is  not  certain  in  our  mind  but  that,  when 
the  principles  which  control  the  reduction  are  more  completely  under- 
stood, these  evils  may  be  lessened ;  yet  we  can  scarcely  persuade  our- 
selves that  by  any  future  observations,  the  state  of  the  question  will 
ever  be  greatly  changed.     We  cannot  but  think,  also,  that  some  con- 
clusions ought  to  be  drawn  from  the  circumstance  that,  since  the  time 
of  Hippocrates  to  the  present  day,  manipulation  has  been  occasionally 
recommended  and  successful  examples  reported;  the  reduction  beino- 
accomplished  in  most  instances  by  processes  identical,  or  nearly  so 
with  those  now  adopted ;  yet  generally  the  writers  appear  to  have 
been  ignorant  of  what  had  been  done  before,  and  indeed,  they  have 
generally  avowed  their  belief  that  the  method  suggested  by  them- 
selves was  altogether  new  and  original.     Possibly,  this  slowness  to 
establish,  and  total  inability  to  sustain  and  perpetuate  a  reputation 
was  not  the  fault  of  the  method,  and  had  no  relation  to  its  failures' 
Until  withm  a  few  years,  the  number  of  surgical  books,  and  especially 
of  niedical  journals,  was  comparatively  very  small,  so  that  valuable 
truths  often  died  with  their  discoverers,  or  were  known  and  remem- 
bered only  by  a  few;   but  it  is  possible,  also,  that  it  has  a  deeper 
significance,  and   that  it  implies  some  defect   in  the  procedure,  or 
serious  danger,  in  consequence  of  which  it  has  from  time  to  time 
lapsed  into  desuetude  and  finally  into  complete  oblivion. 

The  rules  which  the  author  would  give  for  the  employment  of  mani- 
pulation are  very  simple. 

The  patient  being  laid  on  his  back  upon  a  mattress,  the  surgeon 
assuming  that  it  is  a  dislocation  upon  the  dorsum  ilii,  should  seize  the 
toot  with  one  hand  and  the  other  he  should  place  under  the  knee  • 
then,  flexing  the  leg  upon  the  thigh,  the  knee  is  to  be  carefully  lifted 
toward  the  face  of  the  patient,  until  it  meets  with  some  resistance  ;  it 
must  then  be  moved  outwards  and  slightly  rotated  in  the  same  direc- 
tion until  resistance  is  again  encountered,  when  it  must  be  gradually 
brought  downwards  again  to  the  bed.  We  do  not  know  that  the 
whole  process  could  be  expressed  in  simpler  or  more  intelligible  terms 


UPWAEDS    AND    BACKWARDS    ON    THE    DORSUM    ILII.      641 

than  to  say,  that  the  limb  should  follow  constantly  its  own  iuclina- 
tions. 

All  writers  have  united  in  the  necessity  of  flexion ;  and,  indeed, 
with  very  few  exceptions,  the  advocates  of  extension  have  insisted 
upon  carrying  the  dislocated  limb  more  or  less  across  the  sound  one ; 
they  have  also  been  nearly  unanimous  in  their  statements  that  the 
thigh  should  then  be  abducted  and  finally  brought  down.  Nathan 
Smith  has  added  the  injunction  to  rotate  the  shaft  of  the  femur  out- 
wards, and  to  press  gently  upon  the  inside  of  the  knee  while  the  thigh 
is  being  flexed  upon  the  body,  so  as  to  compel  the  head  of  the  bone 
to  hug  the  outer  margin  of  the  acetabulum  and  to  prevent  its  falling 
into  the  ischiatic  notch;  a  suggestion  which  has  been  erroneously  in- 
terpreted by  some  writers  to  mean  that  he  would  carry  up  the  limb 
abducted,  a  thing  which  is  simply  impossible  until  the  reduction  is 
accomplished.  In  adopting  this  practice,  however,  we  must  not  forget 
the  danger  which  we  incur  when  the  limb  is  completely  flexed,  and 
the  head  of  the  femur  is  below  the  edge  of  the  acetabulum,  of  throw- 
ing it  over  into  the  foramen  ovale.  Dr.  Nathan  Smith  has  also  noticed 
the  advantage  which  sometimes  may  be  gained  by  giving  to  the  limb 
at  this  moment  a  slight  rocking  motion. 

These  movements  of  the  limb,  with  perhaps  other  slight  modifica- 
tions, such  as  lifting  the  knee  moderately  when  the  bone  refuses  to 
mount  over  the  margin  of  the  acetabulum,  pressing  with  the  hand 
upon  the  head  of  the  bone,  &c.,  are  all  which  have  been  usually  prac- 
ticed in  successful  manipulation. 

We  repeat,  however,  that  as  a  general  rule,  the  knee  must  be  car- 
ried only  in  those  directions  which  offer  no  resistance,  and  these  will  be 
found  almost  always  to  be  the  same ;  the  knee  of  the  dislocated  femur 
hanging  over  the  sound  one  will  be  made  easily  to  ascend  to  about  a 
right  angle  with  the  body,  we  can  then  carry  it  outwards  a  short  dis- 
tance, probably  not  more  than  four  or  five  degrees ;  at  this  moment, 
frequently  the  thigh  will  begin  tt)  rotate  outwards  of  itself,  and  with 
considerable  force,  or  as  Wathman  says,  "a  self-twisting  of  the  thigh 
occurs  which  cannot  be  prevented  by  fast  holding."  When  this  action 
takes  place  the  reduction  is  immediately  accomplished ;  and  it  is  in 
fact  at  this  moment,  before  the  limb  begins  to  descend,  that  the  bone 
most  frequently  resumes  its  socket.  If  it  does  not,  then  as  soon  as  the 
limb  begins  to  fall  the  reduction  occurs;  generally  with  a  loud  snap. 
It  is  pretty  certain  that  this  manipulation  is  to  fail  if  the  knee  has 
descended  more  than  a  few  inches  without  the  reduction  having  taken 
place ;  and  it  will  be  better  to  repeat  the  manoeuvre  at  once,  rather 
than  to  bring  the  limb  completely  down. 

Generally  anaesthetics  ought  not  to  be  employed,  since  the  opera- 
tion, if  successful,  is  not  usually  painful,  and  we  need  that  the  patient 
should  preserve  his  consciousness  in  order  to  admonish  us  when  we 
are  using  improper  violence.  It  is  probable,  also,  that  the  action  of 
certain  muscles  sometimes  affords  material  assistance  in  the  reduction. 
If,  however,  the  patient  is  very  sensitive,  or  the  parts  about  the  joint 
are  very  tender,  or  manipulation  without  ansesthetics  has  failed,  then 
certainly  these  agents  may  be  properly  and  advantageously  employed. 
41 


642  DISLOCATIONS    OF    THE   THIGH. 

If  we  propose  to  attempt  reduction  by  extension,  it  is  no  longer 
necessary  to  resort  to  tlie  lancet,  antimony,  and  the  hot  bath,  as  pre- 
liminary measures,  since  the  muscles  can  be  at  once  overcome  by  the 
much  more  certain  and  more  powerful  agents,  chloroform,  ether,  &c. 

The  patient  is  therefore  to  be  placed  at  once  upon  a  bed  of  suitable 
height,  reclining  on  his  back,  but  partly  over  upon  the  sound  side. 
Observing  now  the  line  of  the  axis  of  the  dislocated  thigh,  one  strong 
staple  is  to  be  secured  into  the  wall  upon  one  side  of  the  room,  and 
another  upon  the  opposite  side,  both  of  which  shall  correspond  as 
nearly  as  possible  with  the  line  of  the  shaft  of  the  femur.  The  staple 
in  front  of  the  body  will  be  higher  than  the  bed,  and  the  staple  behind 
will  be,  in  the  same  proportion,  lower  than  the  bed.  The  limb  being 
stripped,  two  pieces  of  strong  factory  cloth,  each  about  four  inches 
wide  and  two  feet  long,  should  be  laid  parallel  with  and  on  each  side 
of  the  limb ;  the  centre  of  each  strip  being  about  opposite  that  portion 
of  the  thigh  which  is  just  above  the  two  condyles.  Over  the  centre 
of  these  strips,  above  the  condyles  and  patella,  a  strong  roller,  three 
inches  wide  and  at  least  three  yards  long,  previously  wetted  in  water, 
is  to  be  turned  as  tightly  as  it  can  be  drawn  until  the  whole  roller  is 
exhausted ;  the  extremity  of  the  roller  being  made  fast  with  a  needle 
and  thread  rather  than  with  pins.  The  upper  ends  of  the  side  strips 
are  then  to  be  brought  down  and  tied  to  the  lower  ends,  forming  thus 
two  lateral  loops  upon  which  one  of  the  hooks  of  the  compound  pulleys 
is  to^  be  made  fast,  while  the  other  hook  is  secured  to  the  front  staple 
in  the  wall.  Instead  of  these  rollers  we  may  employ,  if  we  choose,  a  leath- 
ern thigh  belt.  (Fig.  263.)  For  the  purpose  of  counter-extension,  a  sheet 
is  folded  diagonally,  and  its  centre  being  applied  to  the  perineum  of 
the  dislocated  limb,  the  ends  are  tied  firmly  into  the  back  staple.  To 
prevent  the  body  from  moving  laterally,  under  the  action  of  the  pul- 
leys, one  assistant  should  be  seated  upon  the  bed,  with  his  back  against 

Fig.  263. 


Eeduction  of  dislocation  upwards  and  backwards  upon  the  dorsum  ilii,  by  the  pulleys  and  thigh  belt. 

the  side  and  back  of  the  patient,  and  his  right  arm  thrown  over  the 
body;  it  is  well  also  to  station  another  beside  the  sound  limb,  so  as  to 
retain  it  also  in  its  place  upon  the  bed.    Underneath  the  upper  part  of 


UPWARDS   AND    BACKWARDS    ON    THE    DORSUM   ILII.      643 

the  dislocated  limb  a  strong  and  broad  bandage  should  be  placed,  of 
sufficient  length  to  tie  over  the  neck  of  the  surgeon  when  he  is  stand- 
ing about  half  bent  over  the  body  of  the  patient. 

Everything  being  arranged,  and  all  portions  of  the  apparatus  having 
been  sufficiently  tested  to  make  sure  that  nothing  will  give  way  dur- 
ing the  operation,  the  anaesthetic  is  to  be  administered,  and  as  the 
patient  falls  gradually  under  its  influence,  the  action  of  the  pulleys 
should  commence,  and  be  slowly  but  steadily  increased,  a  third  assist- 
ant managing  the  rope,  so  as  to  leave  the  surgeon  unembarrassed,  and 
able  to  direct  his  whole  attention  to  the  position  of  the  trochanter  major 
and  of  the  head  of  the  femur.  In  order  to  this,  he  should  place  one 
hand  upon  each  of  these  prominences,  and  watch  carefully  their  descent. 

The  length  of  time  which  will  be  required  to  bring  down  the  limb 
must  differ  greatly  in  different  persons,  according  to  the  peculiar  cir- 
cumstances of  the  case,  and  the  condition,  age,  &c.,  of  the  patient;  but 
it  must  never  be  forgotten  that  a  slow  and  steady  action  is  much  more 
effective  than  rapid  and  irregular  tractions,  and  it  is  in  this  especially, 
rather  than  in  the  relative  amount  of  power,  that  the  pulleys  possess 
always  so  great  an  advantage  over  the  hands. 

When  tbe  surgeon  finds  that  the  head  of  the  bone  has  nearly  or 
quite  reached  the  socket,  if  it  does  not  take  its  place  spontaneously, 
he  may  place  his  neck  in  the  noose  which  passes  underneath  the  thigh, 
and  lift  upwards,  in  order  to  raise  the  trochanter  major,  and  thus  enable 
the  head  to  rotate  toward  the  acetabulum.  It  is  in  this  part  of  the 
manoeuvre,  and  especially  when  at  the  same  moment  one  of  the  assist- 
ants, after  bending  the  leg  upon  the  thigh  so  as  to  make  of  it  a  lever, 
has  rotated  the  thigh  outwards,  that  the  fracture  of  the  neck  has  gene- 
rally taken  place;  and  we  cannot  be  too  cautious,  therefore,  particu- 
larly in  old  persons,  not  to  bear  very  strongly  upon  the  noose,  nor  to 
permit  the  assistant  to  rotate  outwards  with  great  force. 

If  the  bone  does  not  enter  the  socket,  we  may  increase  or  diminish 
the  flexion,  or  suddenly  release  the  tension,  or,  in  fine,  again  resort  to 
manipulation  alone. 

When  the  reduction  is  accomplished,  the  patient  should  be  laid  upon 
his  back,  with  the  knees  resting  over  a  pillow,  and  tied  together  lightly 
with  a  towel  or  a  strip  of  cotton  cloth.  In  order  also  the  more  cer- 
tainly to  prevent  a  reluxation,  the  thigh  of  the  dislocated  limb  should 
be  gently  rotated  outwards,  by  which  the  head  will  be  pressed  forwards 
against  the  anterior  portion  of  the  capsule. 

Such  an  accident,  however,  as  a  recurrence  of  the  dislocation,  in 
the  case  of  the  femur,  is  exceedingly  rare ;  and  I  should  have  deemed 
it  altogether  impossible,  except  as  the  result  of  considerable  violence 
again  applied,  had  not  at  least  two  examples  been  reported  to  us 
upon  very  excellent  authority.  Malgaigne  says  he  has  himself  seen 
an  example  of  reluxation  upon  the  dorsum  ilii,  occasioned  by  an  un- 
timely movement;^  and  Verneuil  has  seen,  six  days  after  the  reduction 
of  a  dislocation  upon  the  ischiatic  notch,  the  dislocation  reproduced 
by  a  sudden  effort  of  the  patient  to  sit  up.* 

aigne,  op.  cit.,  torn.  ii.  p.  830.  ^  Ibid.,  p.  840. 


eu 


DISLOCATIOISrS    OF    THE    THIGH. 


Of  course,  in  these  remarks  we  mean  to  except  those  cases  in  which 
the  upper  margin  of  the  acetabulum  is  broken  off,  and  the  head  of  the 
femur  has  consequently  lost  its  natural  support  in  this  direction. 

Sir  Astley  Cooper  mentions  the  case  of  a  man  who  could  throw  out 
the  head  of  the  thigh-bone  from  the  acetabulum  at  pleasure,  and  reduce 
it  with  equal  facility.  A  similar  case  is  alluded  to  by  Samuel  Cooper,^ 
and  another  is  related  in  an  inaugural  essay  by  Dr.  Lewis,  of  North 
Carolina,  who  graduated  at  the  University  of  Pennsylvania  in  1841.^ 

These  are  only  examples  of  extraordinary  relaxation  and  extension 
of  the  capsular  ligament. 


Fig,  264. 


§  2.  Dislocations  "Cpwakds  and  Backwards  into  the  Great  Ischiatic 

Notch. 

Si/n. — "Upwards  and  backwards  into  the  ischiatic  notch;"  Sir  A.  Cooper.  "Up- 
wards and  backwards  into  the  great  sacro-sciatic  notch ;"  Lizars.  "Backwards  into 
the  sacro-sciatic  foramen ;"  S.  Cooper.  "  Backwards  into  the  ischiatic  notch  ;"  Liston, 
B.  Cooper,  Miller,  Pirrie,  Erichsen,  Skey,  Gibson.  "  Downwards  and  outwards  on  the 
OS  ischium ;"  Boyer,  Dorsey.  "Backwards  and  downwards  into  the  ischiatic  notch  ;" 
Chelius,  Petit,  Duverney.  "  Upon  the  ischium ;"  Bertrandi.  "  Sacro-sciatic  ;"  Gerdy. 
"  Ischiatic  ;"  Malgaigne. 

Boyer  considers  this  dislocation  as  only  secondary  upon  a  disloca- 
tion upon  the  dorsum  ilii ;  but  it  is  very  certain  that  it  often  occurs 

as  a  primary  accident.  Not  unfre- 
quently,  also,  what  was  primarily  a 
dislocation  into  the  ischiatic  notch, 
becomes  subsequently  a  dislocation 
upon  the  dorsum  ilii. 

Causes. — A  fall  upon  the  foot  or 
knee,  when  the  limb  is  very  much  in 
advance  of  the  body ;  or  the  fall  of  a 
heavy  weight  upon  the  back  and  pelvis 
when  the  thigh  is  nearly,  or  quite  at  a 
right  angle  with  the  body.  Indeed 
the  causes  are  very  similar  to  those 
which  produce  dislocations  upon  the 
dorsum  ilii,  except  that  it  is  necessary 
to  suppose  the  limb  in  a  position  more 
nearly  at  a  right  angle  with  the  trunk, 
at  the  moment  in  which  the  force  is 
applied. 

Pathological  Anatomy. — Mr.  Syme, 
who  dissected  the  body  of  a  man  re- 
cently dead,  whose  thigh  had  been 
dislocated    into    the    ischiatic    notch, 

Dislocation  upwards  and  backwards  into     ^^^^^     the      gluteUS     maximUS     nearly 
the  great  ischiatic  notcli.    (From  A.  Cooper.)      tOm     aSUUdcr,    the    head    of    the    fcmur 


'  S.  Cooper's  First  Lines,  vol.  ii.  p.  386,  Amer.  ed.,  1844. 
'^  Gibson's  Surgery,  vol.  i.  p.  387,  6th  ed. 


UPWAEDS    AND    BACKWAEDS    INTO    ISCHIATIC    N-QTCH.      645 


Fig.  265. 


being  imbedded  in  its  substance ;  the  glutaeus  minimus,  tbe  pyriformis, 
and  the  gemellus  superior  lacerated  ;  the  capsular  ligament  extensively 
torn  close  to  the  edge  of  the  acetabulum,  and  the  round  ligament  com- 
pletely separated  from  the  femur.  The  head  of  the  femur  was  lying 
in  the  great  ischiatic  notch,  upon  the  gemelli  and  the  sacro-sciatic 
nerve,  behind  the  acetabulum  and  a  little  above  it;  being  situated 
between  the  upper  mar- 
gin of  the  notch,  and  the 
great  sacro-sciatic  liga- 
ments.^ Figure  264:  is  a 
representation  of  this  spe- 
cimen. 

Symptoms. — The  posi- 
tion of  the  limb  is  in  some 
cases  nearly  the  same  as 
in  certain  dislocations 
upon  the  dorsum.  It  is 
shortened  usually  about 
a  half  an  inch,  the  thigh 
being  flexed  upon  the 
body,  adducted  and  rotat- 
ed inwards;  but  the  flex- 
ion is  usually  less  than 
in  dislocations  upon  the 
dorsum,  while  on  the 
other  hand,  it  is  some- 
times much  greater. 
Generally  it  is  such  that 
when  the  patient  is 
standing  the  end  of  the 
great  toe  of  the  dislo- 
cated limb  touches  the 
ball  of  the  great  toe  of 
the  sound  limb.  The 
head  of  the  femur  may 
also  often  be  distinctly 
felt  in  its  new  position, 
especially  when  the  limb 
is  moved  upwards  or 
downwards.  The  tro- 
chanter major  is  approxi- 

mateCl    lOWara     tne    ante-  Dislocation  upwards  and  backwards,  into  the  great  IscHatic 

rior  superior  spinous  pro-     notch, 
cess  of  the  ilium. 

Sir  Astley  Cooper  remarks  that  this  dislocation  is  the  most  diffi- 
cult to  detect  and  to  reduce,  and  Mr.  Syme  mentions  a  case  in 
which  the  nature  of  the  accident  was  overlooked  by  himself,  and 
the  thigh  was   not   reduced  until  the  thirteenth  day;^  and   subse- 


1  Amer.  Journ.  Med.  Soi.,  vol.  xxxii.  p.  460. 

2  Ibid.,  vol.  xviii.  p.  242. 


646  DISLOCATIONS    OF    THE    THIGH, 

quently  Mr.  Syme  has  called  attention  to  what  he  considers  as  one  of 
the  most  important  diagnostic  marks;  indeed,  he  says  it  is  never 
absent,  nor  is  it  ever  met  with  in  any  other  injury  of  the  hip-joint, 
"  whether  dislocation,  fracture,  or  bruise ;"  this  is  "  an  arched  form  of 
the  lumbar  part  of  the  spine,  which  cannot  be  straightened  so  long  as 
the  thigh  is  straight,  or  on  a  line  with  the  patient's  trunk.  When  the 
limb  is  raised  or  bent  upwards  upon  the  pelvis,  the  back  rests  flat 
upon  the  bed;  but  so  soon  as  the  limb  is  allowed  to  descend,  the  back 
becomes  arched  as  before  ;"^  but  in  addition  to  this  valuable  sign,  the 
inversion  of  the  toes,  immobility  of  the  limb,  and  the  absence  of 
crepitus,  are  generally  sufficient  in  themselves  to  distinguish  it  from  a 
fracture  of  the  neck. 

Prognosis. — I  have  seen  one  dislocation  of  this  character  which  was 
not  recognized  by  the  surgeon  at  the  time  of  the  receipt  of  the  injury, 
nor  for  some  weeks  afterwards.  This  was  in  a  lad  twelve  years  old, 
who  was  brought  to  me  from  an  adjacent  county  in  August,  1847. 
The  accident  had  happened  eight  weeks  before.  His  limb  was  short- 
ened one  inch ;  it  was  also  forcibly  adducted  and  rotated  inwards. 
Dr.  Colegrove,  a  very  excellent  surgeon,  practicing  near  the  city,  had 
made  a  thorough  attempt  to  reduce  the  dislocation  with  pulleys  a  few 
days  before  he  was  brought  to  me,  and  I  did  not  deem  it  advisable  to 
subject  him  again  to  the  trial.  ISTotwithstanding  the  dislocation  his 
limb  was  quite  useful. 

Treatment. — In  employing  manipulation,  we  may  follow,  with  only 
a  slight  modification,  the  directions  already  given  in  dislocations  upon 
the  dorsum  ilii.  We  find  the  head  of  the  femur  lower,  consequently 
the  extent  of  the  circuit  to  be  described  in  the  manoeuvre  is  diminished, 
but  in  other  respects  the  processes  are  identical. 

We  must  not  forget,  however,  that  there  is  especial  danger  while 
attempting  to  reduce  this  dislocation  by  manipulation  that  the  head 
of  the  bone  will  be  thrown  across  into  the  foramen  thyroideum.  I 
have  already  mentioned  one  case  occurring  under  the  care  of  Dr.  Post 
in  the  New  York  Hospital,  in  which  the  head  of  the  femur,  originally 
in  the  ischiatic  notch,  passed  backwards  and  forwards  between  the 
ischiatic  notch  and  the  foramen  ovale  many  times,  and  which,  although 
the  reduction  was  finally  accomplished,  was  followed  by  morbus  coxa- 
rius.  Parker  mentions  a  second  case  in  the  same  paper,^  in  which  his 
first  attempt  to  reduce  by  manipulation  carried  the  head  of  the  bone 
into  the  foramen  ovale  ;  but  the  second  attempt  was  successful.  Mal- 
gaigne  refers  to  a  patient  of  Lenoir's,  and  to  another  of  his  own,  in 
which  the  head  of  the  bone  was  lodged  under  the  margin  of  the 
acetabulum  during  the  attempts  at  reduction.^ 

On  the  23d  of  March,  1855,  Charles  McCormick,  set.  21,  a  laborer  on 
the  "  State  Line  Railroad,"  was  caught  between  two  cars,  with  his  back 
resting  against  one  car,  and  his  right  knee  against  the  other,  the  right 
thigh  being  raised  to  a  right  angle  with  his  body.     As  the  cars  came 

•  Amer.  Journ.  of  Med.  Sci.,  Oct.  1843,  p.  461,  from  Lond.  and  Edinb.  Month.  Journ., 
July,  1843. 

^  Markoe's  Paper,  N.  Y.  Journ.  of  Med.,  Jan.  1855. 

*  Malgaigne,  op.  cit.,  torn.  ii.  p.  839. 


UPWAEDS   AND   BACKWARDS   INTO    ISCHIATIC   NOTCH.      647 

together  he  felt  a  "  cracking"  at  his  hip-joint,  and  found  himself  im- 
mediately unable  to  walk  or  stand. 

Two  hours  after  the  accident,  assisted  by  ray  son  Theodore,  and 
Austin  Flint,  Jr.,  I  examined  the  limb  carefully,  and  made  arrange- 
ments for  the  reduction  with  the  pulleys,  in  case  the  attempt  by  mani- 
pulation should  fail. 

The  patient  lying  upon  his  back,  I  seized  the  right  leg  and  thigh 
with  my  hands,  the  leg  being  moderately  flexed  upon  the  thigh,  and 
carried  the  knee  slowly  up  toward  the  belly,  until  it  had  approached 
within  twelve  or  fifteen  inches,  when  noticing  a  slight  resistance  to 
further  progress  in  this  direction,  I  carried  the  knee  across  the  body 
outwards,  until  I  again  encountered  a  slight  resistance,  and  immediately 
I  began  to  allow  the  limb  to  descend.  At  this  moment  a  sudden  slip 
or  snap  occurred  near  the  joint,  and  I  supposed  reduction  was  accom- 
plished ;  but,  on  bringing  the  limb  down  completely,  I  found  it  was 
still  in  the  ischiatic  notch.  I  think  the  head  had  slipped  olf  from  the 
lower  lip  of  the  acetabulum,  after  having  been  gradually  lifted  upon  it. 

Without  delay,  I  commenced  to  repeat  the  manipulation,  and  in 
precisely  the  same  manner.  Again,  at  the  same  point,  when  the  limb 
was  just  beginning  to  descend,  a  much  more  distinct  sensation  of  slip- 
ping was  felt,  and  on  dropping  the  limb  it  was  found  to  be  in  place 
and  in  form,  with  all  its  mobility  completely  restored. 

No  anaesthetic  was  employed,  and  no  person  supported  the  body  or 
interfered  in  any  way  to  assist  in  the  reduction.  No  outcry  was  made 
by  the  patient,  yet  he  informed  me  that  the  manipulation  hurt  him 
considerably.  The  amount  of  force  employed  by  myself  was  just 
sufficient  to  lift  the  limb,  and  the  time  occupied  in  the  whole  pro- 
cedure was  only  a  few  seconds. 

After  the  reduction  he  remained  upon  his  back,  in  bed,  eleven  days, 
in  pursuance  of  my  instructions.  At  the  end  of  this  time  he  began  to 
walk  about,  but  was  unable  to  resume  work  until  after  eight  weeks 
or  more.  It  is  probable  that  he  could  have  walked  immediately  after 
the  reduction,  without  much,  if  any  inconvenience,  so  trivial  was  the 
inflammation  which  resulted  from  the  accident.  He  never  complained 
of  pain,  but  only  of  a  slight  soreness  back  of  the  trochanter  major, 
near  the  head  of  the  bone.  This  soreness  continued  several  weeks, 
and  was  especially  present  when  he  bent  forwards.  After  the  lapse 
of  four  months,  when  I  last  saw  him,  he  occasionally  felt  a  pain  at 
this  point  in  stooping,  but  the  motions  of  the  joint  were  free ;  he  walked 
rapidly  and  without  halt. 

If  the  reduction  is  attempted  by  extension,  we  ought  to  remember 
that  the  head  of  the  bone  lies  more  behind  than  above  the  socket,  and 
that  it  is  not  requisite  to  carry  it  downwards  so  much  as  forwards ; 
and  especially  that  it  must  mount  over  the  most  elevated  margin  of 
the  socket,  in  order  to  resume  its  position.  The  extension  ought, 
therefore,  to  be  made  at  an  angle  of  45° ;  and  if  this  is  not  alone  suffi- 
cient, the  head  of  the  bone  should  be  lifted  by  a  jack-towel  upwards 
and  in  the  direction  of  the  socket.  Bransby  Cooper  thought  that  the 
limb  should  be  flexed  quite  to  a  right  angle  whilst  the  extension  was 


648 


DISLOCATIONS    OF    THE    THIGH. 


being  made;  but  this  can  only  be  necessary  when  the  head  of  the  bone 
is  dislocated  directly  backwards. 


Fig.  266. 


Reduction  of  dislocation  upwards  and  backwards  into  the  great  ischiatic  notch,  by  extension. 

Care  must  be  taken  that  the  counter-extending  band  does  not  slide 
off  from  the  pelvis,  toward  the  upper  part  of  the  tbigb,  as  it  is  con- 
stantly disposed  to  do,  when  the  limb  is  so  much  flexed.  This  dis- 
position may  be  restrained  in  some  measure,  by  attaching  to  the 
counter-extending  band  another  band  which  shall  pass  off  from  the 
first  at  a  right  angle,  and  embrace  the  pelvis  upon  the  opposite  or 
sound  side. 

Dr.  Annan,  of  Baltimore,  believes  that  the  great  difiSculty  wbicb 
surgeons  have  experienced  in  their  attempts  to  reduce  this  dislocation, 
has  arisen  from  this  malposition  of  the  counter-extending  band ;  and, 
as  he  has  been  unable  to  prevent  its  sliding  off'  from  the  pelvis  where 
the  method  of  Sir  Astley  Cooper  has  been  tried,  he  suggests  the  fol- 
lowing plan :  The  patient  is  to  be  placed  upon  his  face  on  a  table;  the 
pelvis  secured  by  a  band  passing  around  it,  and  going  off'  laterally  at 
right  angles  from  the  sound  side,  to  be  fastened  to  a  post  or  a  ring 
fixed  in  the  wall ;  another  band  is  to  be  put  around  the  upper  part  of 
the  thigh  of  the  injured  limb,  which  should  be  given  to  the  assistants, 
or  attached  to  the  pulleys,  in  case  they  are  to  be  employed ;  this  band 
also  acting  at  a  right  angle  with  the  axis  of  the  body,  but  in  the 
opposite  direction,  so  as  to  antagonize  the  band  which  acts  upon  the 
pelvis.     The  extending  baud,  made  fast  in  the  usual  manner,  above 


INTO    THE    FORAMEX    THYEOIDEUM.  649 

the  knee,  is  then  to  be  tightened,  but  only  sufficiently  to  prevent  the 
head  of  the  bone  from  ascending.  The  ankle  of  the  dislocated  limb 
should  now  be  laid  hold  of,  and  adducted,  or  drawn  over  the  back  of 
the  sound  limb;  "which,"  says  Dr.  Annan,  "will  force  the  head  of 
the  bone  out  of  the  notch,  and  make  it  describe  the  segment  of  a  circle, 
and  pass  a  little  downwards  in  the  direction  of  the  acetabulum.  Care 
must  be  taken,"  he  adds,  "that  the  extending  band  is  sufficiently 
tightened,  and  that  it  does  not  yield,  otherwise  the  drawing  of  the  leg 
across  the  other  will  only  move  the  head  of  the  bone  in  the  notch,  as 
if  it  was  a  joint.  If  lateral  extension  only  was  employed  in  this  case, 
the  head  of  the  femur  would  be  drawn  out  of  the  notch,  but  it  would 
ascend  upon  the  dorsum  of  the  iliam,  above  the  acetabulum.  Whereas, 
by  simply  drawing  the  limb  laterally  as  much  as  is  required  to  make 
the  extending  band  serve  as  a  fulcrum,  and  then  using  the  leg  as  a 
lever,  the  head  of  the  bone  is  not  only  forced  inwards,  but  is  moved 
downwards,  and  must  necessarily  pass  into  the  socket."^ 

Lente  relates  a  case  under  the  care  of  Dr.  Hoffman,  in  the  Xew 
York  City  Hospital,  in  which,  when  the  extension  was  suddenly 
relaxed  by  cutting  the  cord,  and  the  thigh,  at  the  same  instant,  was 
abducted  and  rotated  outwards,  the  head  of  the  femur  left  the  ischiatic 
notch  and  rose  upon  the  dorsum  ilii,  assuming  a  position  directly 
above  the  acetabulum,  and  below  the  anterior  superior  spinous  pro- 
cess; and  from  which  position  it  was  subsequently,  with  great  diffi- 
culty, returned  to  the  socket.^ 


§  3.  Dislocations  Downwards  and  Forwards  into  the  Foramen 

Thtroideum. 

Syn. — "Downwards  into  the  foramen  ovale  ;"  Sir  A.  Cooper.  "Downwards  into  the 
obtnrator  foramen;"  Lizars.  "Downwards  and  forwards  into  the  foramen  obturato- 
rium  ;"  B.Cooper.  "  Inwards  and  downwards  into  the  oval  hole  ;"  Chelius.  "  Down- 
wards and  forwards  into  the  foramen  ovale;"  Pirrie.  "Downwards  and  inwards;" 
Boyer.     "  Sub-pubic  ;"  Grerdy.     "  Ischio-pubic  ;"  Malgaigne. 

Causes. — In  order  to  produce  this  dislocation  the  limb  must  be,  at 
the  moment  of  the  receipt  of  the  injury,  in  a  position  of  abduction. 
Perhaps  most  often  it  is  occasioned  by  the  fall  of  a  heavy  weight  upon 
the  back  of  the  pelvis  when  the  body  is  bent  and  the  thighs  spread 
asunder. 

Pathological  Anatomy. — The  capsule  gives  way  upon  the  inner  side 
especially;  the  round  ligament  is  torn  from  its  attachment,  and  the 
head  of  the  femur  pressing  forwards  and  downwards,  finds  a  lodge- 
ment upon  the  obturator  externus  muscle,  over  the  foramen  thyroi- 
deum. 

Symptoms. — The  thigh  is  lengthened  from  one  to  two  inches,  greatly 
abducted  and  flexed,  the  body  being  also  bent  forwards  or  flexed  upon 
the  thigh.     The  dislocated  limb  is  advanced  before  the  other,  and  the 

1  Annan,  Amer.  Jouru.  Med.  Sci.,  vol.  xix.  p.  382,  Feb.  1837. 

2  Lente  New  York  Jouru.  Med.,  Nov.  1850,  p.  314. 


650 


DISLOCATIONS    OF   THE    THIGH, 


toes  generally  point  directly  forwards,  but  they  may  incline  either 
outwards  or  inwards.     The  hip  is  flattened ;  the  trochanter  major  is 


Fig.  267. 


Fig.  268. 


Dislocation   downwards  and   forwards  into 
the  foramen  thyroideum. 


Dislocation  downwards  and  forwards  into  the  foramen 
thyroidenm. 

less  prominent  than  upon  the  oppo- 
site side ;  and  the  head  of  the  bone 
may  sometimes  be  felt  in  its  new  posi- 
tion. The  lengthening  of  the  limb 
alone  is  sufficient  to  distinguish  this 
accident  from  a  fracture  of  the  neck. 

Treatment. — It  is  pretty  certain  that 
in  the  following  example  there  was 
a  spontaneous  reduction,  or  rather  I 
ought  to  say,  an  accidental  reduction 
of  a  dislocated  femur  from  the  thyroid 
foramen.  Perhaps  it  was  only  an  example  of  a  partial  luxation ;  of 
which  species  of  forward  luxation  I  shall  hereafter  relate  another  case 
as  having  come  under  my  own  notice. 

Jacob  Lower,  »t.  10,  fell  from  a  tree,  a  height  of  about  twelve  feet, 
to  the  ground.  _  It  is  not  known  how  he  struck.  He  became  imme- 
diately quite  faint,  and  when  he  had  partly  recovered,  he  attempted 
to  get  up,  but  could  not.  He  said  his  leg  was  broken,  and  cried  out 
lustily  whenever  it  was  moved.  The  father  arrived  in  about  an  hour, 
and  found  him  still  lying  on  his  back  where  he  had  fallen,  with  his 
right  leg  carried  away  from  the  other  and  turned  outwards.  He  lifted 
him  up  to  place  him  in  a  small  hand- wagon,  which  was  long  enough  for 
his  body,  but  only  one  foot  and  a  half  in  width.    Finding  that  his  right 


INTO    THE    FORAMEN    THTEOIDEDM.  651 

leg  was  so  much  abducted  as  to  prevent  his  being  laid  in  so  narrow  a 
space,  he  seized  upon  it,  and  with  some  force  pressed  the  knee  inwards 
across  the  opposite  leg,  when  suddenly  it  resumed  its  position  with  a 
loud  snap  like  a  "  cannon,"  I  use  the  language  of  the  father.  On  the 
following  day  I  examined  the  limb  carefully  and  found  its  motions 
free.  He  was,  however,  vomiting  the  contents  of  his  stomach,  and 
passing  blood  from  the  bladder  quite  freely.  The  vomiting  soon 
ceased,  but  the  hemorrhage  from  the  bladder  continued  three  or  four 
days.  On  the  ninth  day  he  walked  out,  and  on  the  twelfth  he  was 
seen  climbing  upon  the  top  of  a  house.  I  saw  him  again  after  the 
lapse  of  a  year,  and  found  that  he  was  still  complaining  of  an  occa- 
sional soreness  in  the  region  of  the  hip-joint. 

If  we  attempt  to  reduce  by  manipulation,  it  will  be  necessary  to 
follow  the  same  rule  which  we  have  stated  as  applicable  to  disloca- 
tions backwards,  namely,  to  carry  the  limb  only  in  those  directions 
in  which  it  is  found  to  move  easily.  Instead,  therefore,  of  holding 
the  leg  in  a  position  of  adduction  while  the  thigh  is  flexed  upon  the 
abdomen,  it  will  be  necessary  to  carry  it  up  abducted ;  and  when  the 
further  progress  of  the  knee  toward  the  belly  is  arrested,  the  limb 
must  be  moved  inwards,  and  finally  brought  down  adducted.  "When 
the  knee  is  about  opposite  the  pubes,  or  a  little  lower  in  its  descent, 
the  femur  should  be  gently  rotated  inwards  for  the  purpose  of  direct- 
ing the  head  toward  the  acetabulum.  The  reduction  may  also  be 
sometimes  facilitated  by  giving  to  the  shaft  of  the  femur  a  slight  rock- 
ing motion  when  it  is  about  to  enter  the  socket;  and  also  by  pressing 
with  the  hand  against  the  head  of  the  bone,  or  by  lifting  at  the  limb 
moderately. 

In  one  of  the  examples  recorded  by  Markoe  (Case  8),  the  reduction 
was  accomplished  in  the  second  attempt,  by  rotating  the  thigh  inwards 
just  as  the  thigh  had  descended  below  a  right  angle  with  the  body, 
in  the  manner  which  we  have  above  directed ;  but  in  a  second  ex- 
ample (Case  9),  a  similar  manoeuvre  carried  the  head  across  into  the 
ischiatic  notch,  while  the  reduction  was  finally  accomplished  by  rotat- 
ing the  thigh  outwards,  and  at  the  same  moment  adducting  the  limb 
strongly  in  a  direction  which  carried  the  knee  behind  the  other  one. 
Markoe  concludes  that  the  latter  mode  is  preferable,  because  it  will 
throw  the  head  of  the  bone  a  little  upwards  as  well  as  outwards ; 
in  which  direction  it  will  find  a  more  gently  inclined  plane  toward 
the  socket.  He  admits,  however,  that  both  methods  may  accomplish 
the  same  result.  But  I  am  quite  certain  that  the  method  by  rotation 
of  the  shaft  of  the  femur  inwards  is  in  general  most  likely  to  succeed. 
In  this  way  also,  I  think,  both  W.  H.  Van  Buren,  of  New  York,^  and 
E.  L.  Brodie,  of  the  U.  S.  Army,  were  successful  \^  but  it  is  especially 
worthy  of  notice  that  Anderson,  so  long  ago  as  1772,  in  the  case 
already  quoted,  when  we  were  considering  the  history  of  reduction  by 
manipulation,  practiced  successfully  almost  precisely  the  same  method. 
In  one  example  mentioned  by  Markoe  (Case  7),  it  is  pretty  evident 

'  W.  H.  Van  Buren,  New  York  Med.  Times,  Jan.  1856,  p.  127. 
2  R.  L.  Brodie,  Memphis  Med.  Recorder,  Sept.  1857,  p.  90;  from  Charleston  Med. 
Rev. 


652 


DISLOCATIONS    OF    THE    THIGH. 


that  the  head  of  the  femur  was  thi'own  into  the  ischiatic  notch,  by  hav- 
ing flexed  the  thigh  too  much,  so  that  "the  knee  touched  the  thorax." 
Indeed,  it  is  questionable  whether  it  will  be  best  ever  to  bring  the 
thigh  much,  if  at  all,  above  a  right  angle  with  the  bod}?-,  since  any- 
further  flexion  can  only  throw  the  head  below  the  acetabulum,  when 
in  fact  it  is  already  too  low. 

July  21,  1858,  Nathaniel  Smith,  a  painter  by  trade,  ^t.  33,  fell  from 
the  second  story  window  of  the  city  post-office,  upon  a  stone  pave- 
ment, striking,  as  he  believes,  upon  the  inside  of  his  right  knee.  I 
saw  him  within  an  hour,  and  found  the  right  tibia  partially  dislocated 
outwards,  the  corresponding  patella  dislocated  completely  outwards,  L 
and  the  right  femur  in  the  foramen  thyroideum.  His  thigh  was  forci-l 
bly  abducted;  slightly  rotated  outwards,  and  lengthened,  by  measure- 
ment made  from  the  pelvis  to  the  ankle,  one  inch  and  a  half.  The 
distance  from  the  anterior  superior  spinous  process  to  the  fold  of  the 
groin  was  ten  inches,  but  upon  the  sound  side  it  was  only  eight  and  a 
half.  The  head  of  the  femur  could  be  distinctly  felt  in  front,  just  under 
the  pubes. 

Having  administered  chloroform,  I  first  reduced  the  tibia  and  the 
patella,  then  seizing  the  thigh  and  leg,  I  flexed  the  thigh  upon  the 
body,  carrying  the  limb  upwards  abducted  until  it  was  nearly  or  quite 
at  a  right  angle  with  the  body,  then  inclining  the  knee  slightly  in- 
wards, I  brought  it  down  again,  and  when  the  thigh  had  nearly 
reached  the  bed,  it  fell  into  its  socket  with  a  dull  flapping  sensation. 
In  every  step  of  the  procedure  I  followed  the  inclination  of  the  limb. 
The  recovery  was  rapid  and  complete. 

Sir  Astley  Cooper  says  that  this  dislocation  is  in  general  reduced 

Fig.  269. 


Sir  Astley  Cooper's  mode  of  reducing  recent  luxations  into  the  foramen  thyroideum. 


UPWAEDS    AND    FORWARDS   UPOIS"   THE    PUBES.  653 

very  easily  by  the  aid  of  pulleys;  at  leasts  if  the  accident  is  recent. 
He  advises  that  the  patient  shall  be  placed  upon  his  back  with  his 
thighs  separated  as  far  as  possible.  The  pulleys  are  to  be  made  fast 
to  a  band  drawn  through  the  perineum  of  the  dislocated  limb,  in  a 
direction  upwards  and  outwards;  while  a  counter-band  is  to  be  passed 
around  the  pelvis  through  the  band-  attached  to  the  pulleys,  and  secured 
to  a  staple,  or  delivered  to  assistants  placed  upon  the  sound  side  of  the 
body.  When  everything  is  arranged,  the  pulleys  should  be  acted  upon 
until  the  head  of  the  femur  is  felt  moving  from  the  foramen  ovale;  at 
this  moment  the  surgeon  must  pass  his  hand  behind  the  sound  limb, 
and  seizing  upon  the  ankle  of  the  dislocated  limb,  adduct  it  forcibly, 
thus  converting  the  limb  into  a  lever  of  the  first  order. 

If  the  dislocation  has  existed  some  time,  he  recommends  that  this 
procedure  shall  be  varied  by  placing  the  patient  upon  his  sound  side 
instead  of  his  back,  and  attaching  the  pulleys  perpendicularly  over 
the  body.  Sir  Astley  especially  cautions  us  not  to  flex  the  thigh  during 
these  manoeuvres,  lest  we  force  the  head  of  the  bone  backwards  into 
the  ischiatic  notch,  from  whence  he  affirms  that  it  cannot  afterwards 
be  returned  to  its  socket ;  but  the  experience  of  surgeons  has  since 
shown  that  this  latter  statement  is  incorrect,  and  that  it  may,  in  some 
cases,  be  afterwards  reduced,  although  it  has  fallen  into  the  ischiatic 
notch,  Mr.  Listen  says  that  this  accident  happened  to  himself  while 
attempting  to  reduce  a  dislocation  of  only  a  few  hours'  standing,  in  a 
young  and  powerful  man,  but  he  had  no  difficulty  in  returning  it  to 
its  first  position.^ 

Brainard,  of  Chicago,  reduced  a  dislocation  of  that  form  of  which 
we  are  now  speaking,  after  both  the  compound  pulleys  and  Jarvis's 
adjuster  had  failed,  by  placing  between  the  thighs  a  piece  of  wood 
wrapped  about  with  several  layers  of  a  wadded  quilt,  and  making 
use  of  this  as  a  fulcrum  upon  which  the  thigh  operated  as  a  lever. 
The  legs  were  simply  pressed  together,  care  being  taken  to  keep  the 
knees  straight.^ 

After  the  reduction  is  accomplished,  the  patient  should  be  laid  upon 
his  back  in  bed,  but  instead  of  rotating  the  limb  outwards,  as  we  have 
advised  after  a  dislocation  upon  the  dorsum  ilii,  or  into  the  ischiatic 
notch,  it  should  be  gently  rotated  inwards,  and  the  knees  thus  bound 
together. 

§  4.  Dislocations  TJpwaiids  and  Forwards  upon  the  Pubes. 

Syn. — "Upwards  and  forwards  on  the  horizontal  branch  of  the  share-bone;"  Che- 
lins.  "Forwards  upon  the  pubes;"  Pirrie.  "On  the  body  of  the  pubes,  below  the 
spine  and  transverse  part  of  the  bone  ;"  Skej.  "  Sur-pubic  ;  "  Gerdy.  "  Ilio-pubic  ;" 
Malgaigne. 

Causes. — This  accident  is  generally  occasioned  by  a  fall  upon  the  foot 
when  the  leg  is  thrown  backwards  behind  the  centre  of  gravity ;  as  in  a 
fall  from  the  back  end  of  a  wagon,  the  foot  being  instinctively  thrown 
backwards  in  order  to  save  the  head ;  or  it  may  happen  to  a  person 

1  Practical  Surg.,  Amer.  ed.,p.  93. 

2  Brainard,  North  Western  Med.  and  Surg.  Journ.,  1852. 


654  DISLOCATIONS    OF   THE   THIGH. 

who,  while  walking,  suddenly  puts  one  foot  into  a  hole,  in  consequence 
of  which  the  pelvis  advances  but  the  leg  and  upper  part  of  the  body 
incline  forcibly  backwards.  Occasionally  it  has  resulted  from  a  fall 
upon  the  back  of  the  pelvis,  or  from  a  severe  blow  received  upon  they 
same  part.  A  patient  was  admitted  under  the  care  of  Dr.  Ure,  into 
St.  Mary's  Hospital,  London,  with  a  dislocation  upon  the  pubes,  occa- 
sioned by  swimming.  His  account  of  it  was,  that,  when  in  the  act  of 
"striking  out"  he  felt  a  catch  in  the  right  groin  which  he  thought  was 
cramp,  and  that  he  was  able  to  walk  after  the  accident,  but  with  a 
good  deal  of  diflBculty.  The  examination  proved  that  he  had  a  dis- 
location upon  the  pubes,  which  Dr.  Ure  easily  reduced.' 

Pathological  Anatomy. — Sir  Astley  Cooper  dissected  the  hip  of  a 
person  whose  thigh  had  been  dislocated  upon  the  pubes  for  some  time, 
the  true  nature  of  the  accident  not  having  been  at  first  recognized. 
The  acetabulum  was  partly  filled  by  bone,  and  partly  occupied  by  the 
trochanter  major,  both  of  which  were  much  altered  in  their  form.  The 
capsular  ligament  was  extensively  torn  and  the  ligamentum  teres 
broken  off"  completely.  The  head  and  neck  of  the  femur  had  torn  up 
Poupart's  ligament,  so  as  to  penetrate  between  it  and  the  pubes,  and 
lay  underneath  the  iliacus  internus  and  psoas  muscles;  the  anterior 
crural  nerve  was  lying  upon  these  muscles,  over  the  neck  of  the  femur. 
The  head  and  neck  were  flattened  and  otherwise  much  changed  in 

Fig,  270. 


Specimen  of  dislocation  upon  the  pubes,  in  St.  Thomas's  Hospital.     (From  Sir  A.  Cooper.) 

form.  Upon  the  pubes  a  socket  was  formed  for  the  neck  of  the  thigh- 
bone, the  head  being  above  the  level  of  the  pubes.  The  femoral  artery 
and  vein  were  to  the  inner  side.  This  specimen  is  still  preserved  in 
St.  Thomas's  Hospital,  Fig.  270. 

In  many  cases,  however,  the  head  of  the  bone  does  not  rise  so  far 
upon  the  pubes,  but  rests  either  upon  its  upper  or  its  anterior  margin. 

'  Medical  News  and  Library,  vol.  xvi.  p.  1 ;  from  Lond.  Lancet,  Nov.  7, 1857. 


UPWARDS    AND    FOEWAEDS   UPON   THE    PUBES. 


655 


Symptoms. — The  tbigh  is  shortened,  abducted,  flexed  slightly,  rarely 
extended,  and  rotated  outwards.  (Fig.  271.)  The  trochanter  major  is 
lost,  or  nearly  so,  while  the  head  of  the  bone  may  be  generally  felt  like 
a  round  ball,  lying  upon  or  in  front  of  the  body  of  the  pubes  to  the 
outside  of  the  femoral  artery  and  vein.  Larrey  saw  a  patient  in  whom 
the  femur  was  placed  nearly  at  a  right  angle  with  the  body;  and  Physick 
once  met  with  a  dislocation  upon  the  pubes  "directly  before  the  aceta- 
bulum," in  which  the  limb  was  not  at  all  shortened,  but,  on  the  con- 
trary, a  very  little  lengthened.' 
Other  surgeons  have  occasionally 
seen  similar  examples. 

The  differential  diagnosis  be- 
tween a  fracture  of  the  neck  of 
the  femur  and  this  dislocation 
may  be  thus  briefly  stated.  In 
the  fracture  there  is  crepitus,  mo- 
bility, slight  eversion  easily  over- 
come, moderate  or  no  shortening, 
no  abduction,  the  trochanter  major 
rotates  on  a  short  radius,  the  head 
of  the  bone  cannot  be  felt.  In 
this  dislocation  there  is  no  crepi- 
tus, the  limb  is  immobile,  the  ever- 
sion is  extreme  and  not  easily 
overcome,  there  is  generally  more 
shortening,  the  thigh  is  abducted, 
the  trochanter  major  rotates  upon 
a  longer  radius,  and  the  head  of 
the  bone  can  generally  be  distinct- 
ly felt  in  its  unnatural  position. 

Prognosis. — Sir  Astley  Cooper 
remarks  that  although  this  acci- 
dent is  easy  of  detection,  he  has 
known  three  instances  in  which  it 
was  overlooked,  and  he  cannot 
but  regard  such  errors  as  evidence 
of  great  carelessness  on  the  part 
of  the  surgeon  who  is  employed. 

The  reduction  has  generally 
been  accomplished,  in  recent  cases, 
with  no  great  difficulty;  and  when 
not  reduced  the  patients  have  oc- 
casionally recovered  with  very 
useful  limbs. 

Treatment. — From    the   several 

reported    examples    of  dislocation     Dislocation  upwards  and  forwards  upon  the  pubes. 

upon  the  pubes  reduced  by  mani- 
pulation, it  would  be  difficult  to  draw  any  practical  conclusions,  since 


Dorsey's  Surgery,  vol.  i.  p.  238,  1813. 


656  DISLOCATIONS    OF    THE   THIGH. 

the  methods  have  differed  so  widely  from  each  other.  I  shall  mention 
only  three,  which  may  be  found  in  our  own  journals.  One  of  these 
has  already  been  mentioned  in  connection  with  the  history  of  this 
process,  as  a  case  of  compound  dislocation,  reduced  by  Dr.  Ingalls,  of 
Chelsea,  Mass.,  and  the  two  remaining  examples  were  both  reported  by 
E.  J.  Fountain,  of  Davenport,  Iowa.  Dr.  Ingalls  succeeded  by  carry- 
ing the  limb  into  its  greatest  state  of  abduction  and  rotating  the  thigh 
inwards ;  the  replacement  of  the  bone  being  aided  also  by  pressing 
upon  its  head  with  his  fingers  thrust  into  the  wound ;  while  Dr.  Foun- 
tain succeeded  equally  in  both  of  his  cases,  by  an  almost  opposite 
mode  of  procedure,  namely,  by  adducting  the  limb  forcibly,  rotating 
the  thigh  inwards  and  then  flexing  the  thigh  upon  the  body.  The 
first  of  Dr.  Fountain's  cases  occurred  in  June,  1854.  The  patient,  an 
adult  male,  had  fallen  from  the  second  story  of  a  house  to  the  ground, 
fracturing  his  lower  jaw,  and  dislocating  his  left  hip.  The  limb  was 
a  trifle  shortened,  and  the  foot  strongly  everted.  The  prominence  of 
the  trochanter  was  lessened,  and  the  head  of  the  bone  could  be  felt 
upon  the  pubes.  Assisted  by  Dr.  Arnold,  he  reduced  the  limb  in  the 
following  manner  :  The  patient  was  laid  on  the  floor,  and  placed  com- 
pletely under  the  influence  of  chloroform.  The  dislocated  limb  was 
then  "seized  by  the  foot  and  knee  and  rotated  outwards,  the  leg  flexed 
and  carried  over  the  opposite  knee  and  thigh,  the  heel  kept  well  up, 
and  the  knee  pressed  down.  This  motion  was  continued  by  carrying 
the  thigh  over. the  sound  one  as  high  as  the  upper  part  of  the  middle 
third,  the  foot  being  kept  firmly  elevated.  Then  the  limb  was  carried 
directly  upwards  by  elevating  the  knee,  while  the  foot  was  held  firm 
and  steady,  at  the  same  time  making  gentle  oscillations  by  the  knee, 
when  the  head  of  the  bone  suddenly  dropped  into  its  socket.'"  The 
time  occupied  was  not  more  than  thirty  seconds,  and  the  force  em- 
ployed was  very  slight. 

The  second  case  occurred  on  the  31st  of  Oct.,  1855,  in  the  person 
of  John  McCarthy,  an  Irish  laborer ;  the  dislocation  having  been 
occasioned  by  falling  with  a  horse,  while  riding.  The  reduction  was 
effected  in  about  twenty  seconds  by  the  same  process,  and  without  the 
aid  of  chloroform. 

It  is  probable  that  no  one  method  will  succeed  equally  well  in  all 
cases ;  but  if  the  head  of  the  bone,  as  in  the  case  dissected  by  Sir 
Astley  Cooper,  has  not  only  actually  surmounted  the  pubes,  but 
pushed  itself  fairly  into  the  pelvis,  then  the  limb  ought  to  be  abducted 
in  the  manner  practiced  by  Ingalls,  and  forcibly  rotated  outwards,  in 
order  that  the  head  may  be  thus  lifted  over  the  pubes;  and  subse- 
quently it  should  be  flexed  upon  the  body,  adducted  and  brought 
down.  But  in  this  manoeuvre  we  ought  to  be  careful  not  to  continue 
the  rotation  outwards  after  the  head  of  the  femur  has  risen  above  the 
pubes,  lest  the  head  and  neck  should  grasp,  as  it  were,  the  psoas 
magnus  and  iliacus  internus  muscles,  underneath  which  they  have 
been  thrust.  On  the  contrary,  it  will  be  necessary  at  this  point  to 
rotate  the  thigh  again  gently  inwards,  which,  by  compelling  the  head 

'  Fountain,  New  York  Journ.  Med.,  Jan.  1856,  p.  69  et  seq. 


UPWARDS    AND    FORWARDS    UPOX    THE    PUBES,  657 

to  hug  the  front  of  the  pubes,  will  enable  it,  while  the  flexion  is  being 
made,  to  slide  downwards  under  these  muscles  toward  the  socket.  If, 
however,  the  head  of  the  bone  has  never  risen  upon  the  summit  of  the 
pubes,  and  is  not  actually  engaged  under  the  muscles  which  pass  over 
it  at  this  point,  then  the  rotation  outwards  will  not  be  necessary  in 
any  part  of  the  procedure. 

Baron  Larrey  has  reported  a  case  of  dislocation  "  before  the  hori- 
zontal portion  of  the  pubes,"  which  he  reduced  "  by  suddenly  raising 
with  his  shoulder  the  lower  extremity  of  the  femur,  while  with  both 
hands  he  depressed  the  head  of  the  bone."^  This  is  the  same  of  which 
we  have  already  spoken  as  being  attended  with  the  unusual  pheno- 
menon of  the  thigh  placed  at  a  right  angle  with  the  body. 

If  reduction  is  attempted  by  extension,  the  patient  ought  to  be  laid 
on  his  back  upon  a  table,  with  the  dislocated  limb  falling  ofi*  slightly 
from  its  side.  The  extending  band,  made  fast  above  the  knee,  should 
then  be  secured  to  a  staple  in  the  line  of  the  axis  of  the  dislocated 
thigh,  and  of  course,  below  the  table;  while  the  counter-extending 
band,  crossing  under  the  perineum,  should  be  made  fast  in  the  same 
line,  above  the  level  of  the  table,  and  beyond  the  head  of  the  patient. 

When  extension  is  commenced,  and  the  head  of  the  femur  has 
begun  to  move,  the  reduction  may  sometimes  be  facilitated  by  lifting 

Fig.  272. 


Eeduction  of  dislocation  upon  the  pntea,  bv  extension. 

the  upper  part  of  the  thigh  with  a  jack  towel  or  a  band  passed  under 
the  thigh  and  over  the  neck  of  the  surgeon,  as  we  have  recommended 
in  both  of  the  backward  dislocations. 

1  Larrey,  Lond.  Med.-Chir.  Eev.,  Dec.  1S20,  p.  500 ;  vol.  i.  first  ser.,  from  Bullet,  de 
la  Fac.  de  Med.,  No.  1. 


42 


658  DISLOCATIONS    OF    THE    THIGH. 


§  5.  Anoma-lous  Dislocations,  or  Dislocations  which  do  not  properly 
belong  to  either  oe  the  four  principal  divisions  before  described.^ 

1.  Dislocations  directly  Upwards. 
Syn. — "  Sus-Cotyloidiennes  ;"  Malgaigne.     "  Sixth  dislocation  ; "  Miitter. 

Malgaigne  affirms  that  the  head,  in  this  dislocation,  is  situated 
external  to  the  anterior  inferior  spinous  process,  and  about  one  inch 
below  the  anterior  superior  spinous  process.  But  this  position  is  not 
uniform.  It  may  be  found  in  front  of  the  inferior  process  or  above 
as  well  as  behind,  or  external  to  it. 

The  symptoms  which  characterize  this  accident,  are  shortening  of 
the  limb,  slight  abduction  and  extension,  with  extreme  eversion  or 
rotation  outwards.  The  eversion  of  the  toes,  together  with  the  slight 
amount  of  shortening  which  has  in  general  been  observed,  has  led 
several  times  to  the  supposition  that  it  was  a  fracture  of  the  neck  of 
the  femur;  but  the  rigidity,  and  the  position  of  the  trochanter  and 
head  will  usually  render  the  diagnosis  clear. 

Cummins  reports  a  case  which  occurred  in  the  practice  of  Gibson, 
of  New  Lanark,  where  the  head  of  the  bone  was  believed  to  be  situated 
just  below  the  anterior  superior  spinous  process,  and  inwards  toward 
the'pubes.  The  limb  was  shortened  fully  three  inches;  the  toes 
everted ;  adduction  and  abduction  were  exceedingly  painful  and  diffi- 
cult, but  flexion  was  more  easily  performed.  The  head  of  the  bone 
could  be  felt  in  its  new  position,  especially  when  the  thigh  was  moved. 
At  first  it  was  supposed  to  be  a  fracture,  but  this  error  having  been 
corrected,  the  surgeons  proceeded  to  attempt  reduction  on  the  eleventh 
day.  Extension  was  made  by  pulleys,  and  when  the  head  of  the  bone 
had  descended  to  the  margin  of  the  cavity,  Mr.  Gibson  lifted  the  upper 
end  of  the  femur  by  means  of  a  towel,  at  the  same  moment  pressing 
the  knee  toward  the  opposite  thigh  and  forcibly  rotating  the  limb 
inwards;  by  which  means  the  reduction  was  accomplished.^ 

Lente  has  seen  the  head  of  the  femur  in  the  same  position  as  in  the 
case  reported  by  Cummins,  not  as  a  primitive  dislocation,  but  conse- 
quent upon  an  attempt  to  reduce  a  dislocation  into  the  ischiatic  notch. 
The  shortening  was  about  two  inches;  the  limb  very  much  rotated 
outwards ;  the  rotundity  of  the  affected  hip  greater  than  that  of  the 
other,  and  the  trochanter  major  one  inch  further  removed  from  the 

'  Malgaigne,  Traite  des  Frac.  et  des  Lux.,  torn.  ii.  p.  869  et  seq.  Samnel  Cooper, 
First  Lines,  vol.  ii.  p.  391.  Pirrie's  Surg.,  Amer.  ed.,  1852,  p.  275.  Skey's  Surg.,  Amer. 
ed.,  1851,  p.  110  et  seq.  Gibson's  Surg.,  sixth  Amer.  ed.,  vol.  i.  p.  386.  Guy's  Hos- 
pital Reports,  vol.  i.  1836,  pp.  79  and  97  ;  vol.  iii.  1838,  p.  163.  London  Lancet, 
Lond.  ed.,  vol.  i.,  1848,  p.  184;  voL  ii.,  1840,  p.  281 ;  vol.  i.,  1845,  p.  412;  vol.  ii.  p. 
159.  London  Med.  Gaz.,  vol.  xix.  pp.  657  and  659  ;  vol.  x.  p.  19  ;  vol.  xxxiii.  p. 
404.  Med.-Chir.  Trans.,  vol.  xx.  p.  112.  Leute's  paper  on  "  Anomalous  Dislocations 
of  the  Hip-Joint,"  in  New  York  Journ.  Med.  for  Nov.  1850,  p.  314  et  seq.  Philadelphia 
Med.  Examiner,  No.  51.  Amer.  Journ.  Med.  Sci.,  vol.  xvi.  p.  14.  New  York  Med. 
and  Phys.  Journ.,  1826,  vol.  v.  p.  597. 

^  Cummins,  Guy's  Hospital  Reports,  vol.  iii.  p.  163,  1838. 


AXOiTALOUS    DISLOCATION'S.  659 

anterior  superior  spinous  process.  The  head  of  the  bone  could  be 
felt  distinctly  in  its  new  position. 

The  reduction  was  effected  finally  with  pulleys,  by  the  aid  of  chlo- 
roform, and  by  rotation  of  the  limb  in  various  directions.^ 

Morgan  also  reports  a  case  in  which  the  head  of  the  femur  was 
above  the  acetabulum,  and  a  little  to  the  outside  of  the  ilio-pectineal 
eminence.^ 

In  a  majority  of  cases  these  dislocations  have  been  reduced  by  ma- 
nipulation alone,  or  by  manipulation  aided  by  pressure.  The  limb 
should  be  seized  in  the  usual  manner,  at  the  knee  and  ankle,  car- 
ried up  toward  the  face,  abducted,  then  rotated  inw^ards,  gently  ad- 
ducted,  and  finally  brought  down  again  to  the  bed.  At  the  moment 
when  the  rotation  and  adduction  commence,  the  head  of  the  bone 
should  be  pressed  toward  the  socket  by  the  hands,  and,  if  necessary, 
lifted  a  little  over  the  margin  of  the  acetabulum,  by  moderate  exten- 
sion at  a  right  angle  with  the  body. 


2.  Dislocations  Doicnicards  and  Backicards  upon  the  Posterior  Part  of  the 
Body  of  the  Ischium,  'between  its  Tuberosity  and  its  Spine. 

James  C ,  set.  35,  was  admitted  to  the  Pennsylvania  Hospital  on 

the  23d  of  January,  1835,  under  the  care  of  Dr.  Hewson.  The  patient, 
a  muscular  man,  had  been  crushed  under  a  falling  roof,  and,  as  he 
thought,  with  his  right  thigh  separated  from  his  body.  When  received 
into  the  hospital,  one  hour  after  the  accident,  the  right  thigh  was  flexed 
upon  the  pelvis,  and  rested  upon  the  left;  the  right  leg  was  also  flexed 
upon  the  thigh ;  the  knee  was  below  its  fellow,  the  toes  turned  in- 
wards, and  the  whole  limb  shortened  at  least  one  inch.  The  head  of  the 
bone  could  be  felt  distinctly  resting  upon  that  portion  of  the  ischium 
which  lies  between  the  acetabulum,  the  tuberosity  of  the  ischium,  and 
the  spine. 

On  the  following  day,  the  muscles  of  the  patient  having  been  suffi- 
ciently relaxed  by  suitable  means,  the  pulleys  were  applied  ;  but,  after 
a  second  attempt,  some  of  the  bands  having  given  way  suddenly,  the 
pulleys  were  removed,  when  it  was  found  that  the  reduction  had  been 
accomplished,  although  neither  the  patient  nor  his  attendants  had 
noticed  the  return  of  the  bone  to  its  socket.  For  several  days  there 
was  entire  loss  of  sensibility  and  motion  in  the  leg,  owing  probably  to 
the  pressure  which  had  been  made  upon  the  sciatic  nerve;  but  these 
symptoms  gradually  disappeared,  and  at  the  time  when  the  case  was 
reported,  about  two  months  after  the  accident,  he  was  walking  with 
crutches. 

Dr.  Kirkbride,  who  has  reported  this  unusual  case  of  dislocation, 
doubts  whether  the  extension  was  necessary  to  the  reduction,  as  the 
head  of  the  bone  was  brought  very  near  the  margin  of  the  acetabulum 

1  Lente.  Ne\r  York  Jonm.  of  Med.,  Nov.  1850,  p.  314. 

2  Pirrie's  Surgery,  p.  276.     See  also  Phil.  Med.  Exam.,  No.  51,  Mutter's  paper. 


660  DISLOCATIONS    OF    THE    THIGH. 

by  lifting  the  thigh  with  a  towel,  and  it  probably  afterwards  entered 
the  socket  so  soon  as  the  extension  was  relaxed.* 
Malgaigne  has  referred  to  several  similar  examples. 

3.  Dislocations  Downwards  and  Backwards  into  the  lesser  or  lower  Ischi- 

atic  Notch. 

Syn. — "BeMnd  tuber  ischii;"  Gibson,  S.  Cooper.     "Fiftb  dislocation  ;"  Gibson. 

September  7,  1821,  Charles  Lowell,  of  Lubec,  Mass.,  was  riding  a 
spirited  horse,  when  the  animal,  being  restive,  suddenly  reared  and  fell 
back  on  his  rider,  in  such  a  manner  as  that  the  weight  of  the  horse 
was  received  on  the  inside  of  the  left  thigh ;  Mr.  Lowell  having  fallen 
on  his  back,  a  little  inclined  to  the  left  side.  The  surgeon,  who  was 
immediately  called,  recognized  it  as  a  dislocation,  and  thought  he  had 
succeeded  in  reducing  it;  but  a  day  or  two  later  it  was  seen  by  a 
second  surgeon,  who  declared  that  it  was  still  out  of  place,  and  re- 
peated the  attempt  at  reduction,  but  without  success,  as  the  result 
proved. 

In  December  of  the  same  year  Mr.  Lowell  called  upon  John  C. 
Warren,  of  Boston,  who  was  now  able  to  determine,  easily,  as  he 
affirms,  the  precise  character  of  the  accident.  The  limb  was  elongated, 
contracted,  and  the  head  could  be  felt  in  its  unnatural  position.  By 
advice  of  Dr.  Warren,  he  was  taken  to  the  Massachusetts  General 
Hospital,  and  a  persevering  attempt  was  there  made  to  reduce  the 
bone,  but  with  no  better  success  than  had  attended  the  efforts  pre- 
viously made.^ 

Mr.  Keate  has  reported  a  case  produced  in  a  very  similar  way  by 
a  horse  having  fallen  backwards  with  the  rider  into  a  deep  and  narrow 
ditch ;  but  the  position  of  the  limb  was  somewhat  extraordinary,  con- 
sidering that  it  was  a  dislocation  backwards,  the  whole  limb  being 
very  much  abducted  and  the  toes  being  turned  outwards,  as  if  the  head 
of  the  bone  was  in  front  of  the  tuber  ischii,  rather  than  behind  it. 
The  thigh  and  leg  were  much  flexed,  and  the  whole  limb  was  short- 
ened from  three  to  three  inches  and  a  half.  The  head  of  the  femur 
could  be  distinctly  felt  "  inferior  to  the  ischiatic  notch,  and  on  a  level 
with  the  tuberosity  of  the  ischium."  In  the  first  attempt  at  reduction 
the  head  of  the  bone  was  thrown  into  the  foramen  ovale,  from  which 
it  was,  however,  after  one  or  two  more  attempts  by  extension,  and  by 
lifting  with  a  jack-towel,  restored  to  the  socket.  Mr.  Keate  believes 
that  the  dislocation  was  originally  into  the  foramen  ovale,  but  that  in 
the  struggles  made  by  the  patient  to  extricate  himself,  it  was  thrown 
backwards  into  the  position  in  which  he  found  it.^ 

Mr.  Wormald  has  reported  a  primitive  accident  of  the  same  kind, 
occasioned  by  jumping  from  a  third  story  window.  The  patient  died 
soon  after,  and  at  the  autopsy  the  head  of  the  femur  was  found  under 

'   Kirkbride,  Amer.  Journ.  of  Med.  Sci.,  vol.  xvi.  p.  13. 

2  New  York  Med.  and  Phys.  .Journ.,  vol.  v.  p.  597  ;  1826.  Letter  to  the  Hon.  Isaac 
Parker,  &c.,  by  John  C.  Warren;  1826.     North  Amer.  Med.  Journ.,  vol.  iii.  p.  169. 

3  Amer.  Journ.  Med.  Sci.,  vol.  xvi.  p.  226, 1835.    From  Loud.  Med.  Gaz.,  vol.  x.  p.  19. 


ANOMALOUS    DISLOCATIONS.  661 

the  outer  edge  of  the  gluteeus  maximus,  projecting  through  the  torn 
capsule  opposite  the  upper  part  of  the  tuber  ischii.  The  shaft  of  the 
femur  lay  across  the  pubes,  and  the  limb  was  considerably  shortened 
and  turned  inwards.^ 

4.  Dislocations  directly  Downwards. 

Syn. — "  Sous-cotyloidiennes  ;"  Malgaigne. 

The  following  is  one  of  several  similar  examples  now  upon  record : — 
A  man,  £et.  60,  was  admitted  into  the  London  Hospital  under  the 
care  of  Mr.  Luke.  A  dislocation  of  the  left  femur  was  easily  diagnos- 
ticated, but  the  symptoms  were  peculiar,  inasmuch  as  the  limb  was 
lengthened  one  inch,  without  either  inversion  or  eversion;  yet  the 
head  of  the  bone  could  be  easily  felt,  and  was  thought  to  be  in  the 
ischiatic  notch.  By  manipular  movements  reduction  was  easily  effected 
about  an  hour  after  the  accident.  The  man  subsequently  died  from 
the  effects  of  broken  ribs.  At  the  autopsy,  Mr.  Forbes,  the  house- 
surgeon,  before  dissecting  the  parts,  again  dislocated  the  bone.  This 
was  done  with  ease,  and  it  was  clear  that  the  original  form  of  disloca- 
cation  had  been  reproduced,  as  the  bone  could  not  be  made  to  assume 
any  other  position.  The  head  of  the  bone  proved  to  be  displaced 
neither  into  the  ischiatic  notch  nor  the  thyroid  hole,  but  midway  be- 
tween the  two,  immediately  beneath  the  lower  border  of  the  acetabulum. 
The  gemellus  inferior  and  the  quadratus  femoris  had  been  torn,  the 
ligamentum  teres  had  been  wholly  detached,  and  there  was  a  laceration 
in  the  lower  part  of  the  capsular  ligament.'^ 

Dr.  Blackman,  of  Cincinnati,  informs  me  that  in  Jan.  1859,  he  re- 
duced a  sub-cotyloid,  incomplete  dislocation,  in  a  man  aet.  70,  by 
manipulation.  Dr.  Judkins  lifting  the  thigh  upwards  and  outwards  by 
means  of  a  towel,  while  Dr.  Blackman  first  flexed  and  then  abducted 
the  limb. 

5.  Dislocations  Forwards  into  the  Perineum. 

Syn. — "Perineales  ;"  Malgaigne.  "  Luxation  sur  la  branche  ascendante  del'iscliion." 
D'Amblard.     "  Inwards  on  the  ramus  of  the  os  pubis  ;"  Skey. 

D'Amblard  published  an  example  of  this  accident  in  1821 ;  occa- 
sioned by  a  violent  muscular  exertion  made  by  the  patient  in  an  effort 
to  spring  into  his  carriage,  the  symptoms  attending  which  did  not 
differ  materially  from  those  which  were  found  to  be  present  in  the  two 
following  examples,  except  that  while  in  Parker's  patient  the  toes  were 
turned  slightly  inwards,  in  D'Amblard's  patient  they  were  a  little  turned 
outwards.^ 

Mr.  E ,  set.  35,  a  calker  by  occupation.  The  injury  was  re- 
ceived while  at  work  under  the  bottom  of  a  canal  boat,  July  20, 1831, 
the  boat  being  raised  upon  props  three  and  a  half  feet  long.  The 
patient  was  standing  yqtj  much  bent  forwards,  with  his  feet  far  apart, 

1  Wormald,  Lond.  Med.  Gaz.,  1836. 

2  Luke,  Med.  News  and  Library,  vol.  xvi.  p.  34,  March,  1858  ;  from  Med.  Times  and 
Gaz.,  .Jan.  2,  1858. 

^  Malgaigne,  op.  cit.,  torn.  ii.  p.  876. 


662  DISLOCATIONS    OF    THE    THIGH. 

between  which  lay  a  piece  of  round  timber  one  foot  in  diameter,  when 
the  props  gave  way,  letting  the  whole  weight  of  the  boat  upon  him- 
self and  his  companions.  One  of  the  workmen  was  killed  outright.  On 
extricating  Mr.  E.  from  his  situation,  the  left  leg  and  thigh  were  found 
extended  at  a  right  angle  with  the  body,  the  toes  turned  slightly  in- 
wards, the  natural  form  of  the  nates  was  lost,  and  the  head  of  the 
femur  could  be  felt  distinctly  moving,  when  the  limb  was  rotated,  in 
the  perineum,  behind  the  scrotum,  and  near  the  bulb  of  the  urethra. 

For  the  purpose  of  reduction,  the  patient  was  laid  on  his  back  upon 
a  table,  and  the  pelvis  made  fast  by  a  muslin  band.  Extension, 
accompanied  with  moderate  rotation,  was  then  made  in  a  direction 
outwards  and  downwards,  bringing  the  head  of  the  bone  over  the 
ascending  ramus  of  the  ischium,  beyond  which  it  was  lying,  into  the 
foramen  thyroideum  ;  and  from  this  position  the  bone  was  replaced  in 
the  acetabulum,  by  carrying  the  dislocated  limb  forcibly  across  the 
opposite  one.     The  patient  soon  recovered  the  use  of  the  joint.^ 

J,  B.,  an  Irishman,  get.  40,  on  entering  the  St.  Louis  Hospital,  gave 
the  following  account  of  his  accident,  which  had  occurred  six  hours 
previously.  He  was  engaged  in  excavating  earth,  and  having  under- 
mined a  bank,  it  unexpectedly  fell  upon  his  back  while  he  was  stand- 
ing in  a  bent  position,  with  his  thighs  stretched  widely  apart.  The 
weight  crushed  him  to  the  earth,  breaking  both  bones  of  his  right  leg, 
the  radius  of  the  same  side  and  dislocating  the  left  hip  into  the  peri- 
neum. The  thigh  presented  a  peculiar  appearance,  being  placed  quite 
at  a  right  angle  with  the  body,  but  somewhat  inclined  forwards.^  The 
part  of  the  hip  naturally  occupied  by  the  trochanter  major  presented  a 
depression  deep  enough  to  receive  the  clenched  fist;  while  the  head  of 
the  bone  could  be  both  seen  and  felt  projecting  beneath  the  skin  of  the 
raphe  in  the  perineum.  Rotation  of  the  limb,  which  was  difficult  and 
excessively  painful,  rendered  the  position  of  the  head  still  more  mani- 
fest. The  patient  had  also  retention  of  urine,  occasioned  probably  by 
the  pressure  of  the  femur  upon  the  urethra.  Having  dressed  the 
fractures.  Dr.  Pope  placed  the  patient  under  the  full  influence  of  chlo- 
roform, and  then  proceeded  to  reduce  the  dislocated  thigh  ;  for  which 
purpose  "two  loops  were  applied,  interlocking  each  other  in  the  groin, 
and  using  the  leg  as  a  lever,  extension,  by  means  of  the  pulleys,  was 
made  transversely  to  the  axis  of  the  body.  A  steady  force  was  kept 
up  for  a  short  time,  and  the  thigh-bone  glided  into  its  socket  with  a 
snap  that  was  heard  by  every  attendant  and  patient  in  the  large  ward."^ 


§  6.  Ancient  Dislocations  of  the  Femur. 

Says  Sir  Astley  Cooper :  "  I  am  of  opinion  that  three  months  after 
the  accident,  for  the  shoulder,  and  eight  weeks  for  the  hip,  may  be 
fixed  as  the  period  at  which  it  would  be  imprudent  to  attempt  to  make 

1  W.  Parker,  New  York  Med.  Gaz.,  1841 ;  N.  Y.  Journ.  Med.,  March,  1852,  p.  188. 
^  Pope,  St.  Louis  Med.  and  Surg.  Journ.,  July,  1850;  N.  Y.  Journ.  Med.,  March, 
1852,  p.  198. 


ANCIENT    DISLOCATIONS    OF    THE    FEMUR.  663 

the  reduction,  except  in  persons  of  extremely  relaxed  fibre,  or  of 
advanced  age.  At  the  same  time,  I  am  fally  aware  that  dislocations 
have  been  reduced  at  a  more  distant  period  than  that  which  I  have 
mentioned  ;  but  in  many  instances  the  reduction  has  been  attended 
with  the  evil  results  which  I  have  just  been  deprecating."  A  remark 
which  later  surgeons  do  not  seem  always  to  have  correctly  understood, 
or  which,  if  they  have  understood,  they  have  not  correctly  repre- 
sented;  since  it  has  many  times  been  affirmed  of  this  distinguished 
surgeon,  that  he  regarded  reduction  of  the  hip  as  impossible  after 
eight  weeks,  and  they  have  proceeded  to  cite  examples  which  would 
prove  that  he  was  in  error.  But  long  before  Sir  Astley's  day,  Gockel 
mentioned  a  case  of  reduction  of  the  femur  after  six  months,  and 
Guillaume  de  Salicet  declared  that  he  had  reduced  a  similar  dislocation 
after  one  year,'  and  Sir  Astley  says,  that  he  is  "fully  aware"  of  the 
existence  of  such  facts ;  yet  with  a  knowledge  of  what  has  so  frequently 
followed  these  attempts,  he  would  not  recommend  the  trial  after  eight 
weeks,  except  under  the  circumstances  by  him  stated ;  and  notwith- 
standing the  number  of  these  reported  successes  has  been  considerably 
increased  in  our  day,  we  suspect  that  Sir  Astley's  rule  will  continue 
to  govern  experienced  and  discreet  surgeons.  Two  examples  which 
have  recently  been  published  of  successful  reduction  after  six  months 
by  manipulation,  would  encourage  a  hope  that  the  period  might  be 
greatly  extended,  were  it  not  that  manipulation  also  has  already  failed 
many  times  in  the  case  of  ancient  luxations,  and  that  the  attempt  has 
sometimes  been  followed  with  disastrous  results,  even  in  recent  cases. 

The  following  are  the  two  examples  of  reduction  by  manipulation 
after  the  lapse  of  six  months : — 

On  the  21st  of  March,  1856,  a  man  presented  himself  at  the  Com- 
mercial Hospital,  Cincinnati,  with  a  dislocation  of  the  femur  upon  the 
dorsum  ilii,  of  six  months'  standing.  The  limb  was  shoi^tened  two 
inches.  Dr.  Blackman,  under  whose  care  he  was  admitted,  adminis- 
tered chloroform,  and  by  manipulating  after  the  method  described  by 
Dr.  Eeid,  the  reduction  was  accomplished.^ 

In  a  letter  addressed  to  me  by  Dr.  Blackman,  and  dated  April  21st, 
1859,  he  informs  me  that  this  patient  presented  himself  again  before 
the  class  about  six  months  since,  and  the  restoration  of  the  functions 
of  the  limb  was  found  to  be  complete. 

The  second  example  occurred  in  the  practice  of  Martial  Dupierris,  of 
Havana,  Cuba.  A  Chinese  boy  named  A-sin,  aged  about  sixteen 
years,  arrived  at  Havana  on  the  fourth  of  June,  1856,  suflering  under 
a  severe  illness,  which  confined  him  for  a  month  or  more  to  his  bed, 
and  the  existence  of  the  dislocation  was  not  discovered  until  he  had 
sufficiently  recovered  to  rise  upon  his  feet.  It  was  then  ascertained 
that  he  had  a  dislocation  of  the  left  femur  upon  the  dorsum  ilii.  Upon 
inquiry,  Dr.  Dupierris  learned  that  the  accident  had  occurred  be- 
fore leaving  China,  a  period  of  more  than  six  months.     The  boy  was 

'  Malgaigne,  op.  cit.,tom.  ii.  p.  185  ;  from  GalliciniumMedico-practicum,  Ulm,  1700, 
p.  288. 
,      ^  Blackman,  Ohio  Med.  and  Surg.  Joum.,  vol.  viii.  p.  522. 


QQ'^  DISLOCATIONS    OF    THE    THIGH. 

Still  feeble,  the  limb  somewhat  emaciated,  and  instead  of  being  rigid 
from  muscular  contraction,  all  the  muscles  "  were  in  a  flaccid°cou°di- 
tion,  except  the  great  gluteal,  which  was  painful  to  the  touch."  Deem- 
ing the  use  of  anesthetics  improper,  on  account  of  the  boy's  feeble 
condition,  these  agents  were  not  employed.  Dr.  Dupierris  describes 
the  method  of  reduction  as  follows  :  "  The  body  being  held  by  two 
assistants  by  means  of  two  bands,  one  of  which  passed  beneath  the 
perineum,  and  the  other  under  the  axilte,  traction  was  made  upon  the 
limb  by  two  strong  and  intelligent  assistants.  The  movement  of  the 
head  of  the  bone,  resulting  from  this  manoeuvre,  was  very  limited, 
even  when  the  force  was  much  increased ;  and  the  excruciating  pain| 
which  the  patient  referred  to  the  iliac  region,  compelled  us  for  the 
moment  to  desist. 

"The  following  day,  the  patient  having  obtained  a  tolerable  night's 
rest  by  means  of  a  narcotic  potion,  I  concluded  to  attempt  the  reduc- 
tion by  flexion,  believing  that  I  could  thus  better  prevent  any  accident 
which  the  necessary  force  might  produce;  the  operator,  in  adopting 
this  method,  haying  it  in  his  power  to  follow  the  head  of  the  bone  by 
pressure  upon  it  with  the  hand,  aiding  its  movement  in  the  proper 
direction,  or  correcting  any  deviation  that  may  occur.  The  emaciated 
condition  of  the  boy  was  eminently  favorable  for  such  a  procedure. 

"The  patient  being  placed  upon  his  back,  and  the  trunk  of  the  body 
made  steady  by  assistants,  with  the  left  hand  I  grasped  the  upper 
part  of  the  leg,  placed  the  right  hand  upon  the  head  of  the  bone  in  the 
iliac  fossa,  and  then  proceeded  to  flex  the  leg  upon  the  thigh,  and  the 
thigh  upon  the  pelvis.  By  this  movement  the  great  gluteal  muscle 
was  relaxed,  and  the  head  of  the  bone  advanced,  while  with  the  right 
hand  T  directed  the  latter  toward  the  cotyloid  cavity.  As  soon  as  I 
judged  the  head  to  be  immediately  above  the  centre  of  the  socket,  I 
extended  the  leg,  the  thigh  remaining  flexed  at  a  right  angle ;  and 
then  using  the  limb  as  a  lever,  I  rotated  it  from  within  outwards,  and 
at  the  same  time  extended  it  by  making  a  movement  of  circumduction 
in  a  similar  direction.  When  by  these  procedures  the  limb  was 
brought  near  to  its  opposite  fellow,  a  snap  audible  to  the  assistants, 
and  of  a  deeper  character  than  is  ordinarily  observed  in  the  reduction 
of  recent  dislocations,  indicated  the  return  of  the  head  of  the  bone  to 
its  natural  position ;  a  fact  which  was  further  substantiated  by  the 
establishment  of  the  original  length  and  form  of  the  member  and  the 
subsidence  of  the  pain. 

"  The  after-treatment  consisted  in  placing  a  pad  between  the  knees, 
and  another  between  the  internal  malleoli,  and  confining  the  limbs 
together  by  two  bands,  one  above  the  knees,  and  the  other  around  the 
lower  part  of  the  legs.  But  in  spite  of  these  precautions  to  prevent 
re-displacement,  the  next  morning  I  found  that  the  dislocation  had 
been  reproduced.  It  was  again  reduced,  but  for  three  successive 
days  there  was  a  re-displacement.  After  this,  however,  the  head  of 
the  bone  kept  its  place;  passive  motion  was  daily  employed,  and  all 
suffering  ceased.  After  twenty  days  of  rest,  and  a  liberal  use  of  the 
lactate  of  iron,  the  patient  was  allowed  to  get  up;  and,  being  provided 
with  a  pair  of  crutches,  upon  which  he  exercised  himself°daily,  im-  * 


PAETIAL    DISLOCATIONS    OF    THE    FEMUR.  665 

proved  very  rapidly.  The  muscles  gradually  recovered  their  bulk 
and  vigor;  and  at  the  end  of  forty-eight  days  he  was  enabled  to  walk 
without  crutches,  although  with  some  fear  of  falling.  About  the 
middle  of  August,  he  was  put  to  work  in  a  cigar  manufactory,  and 
has  continued  well  ever  since." 


§  1.  Partial  Dislocations  op  the  Femur. 

Malgaigne  declares  that  certain  experiments  made  upon  the  cadaver 
led  him,  at  one  time,  to  the  conclusion  that  all  primitive  luxations  of 
the  femur  were  incomplete,  and  that  the  old  complete  luxations  found 
in  autopsies,  had  become  so  consecutively.  Later  observations  have 
taught  him  to  correct  this  error,  yet  he  still  finds  "  incomplete  back- 
ward luxations  quite  common,  and  incomplete  dislocations  in  all  the 
other  directions  much  more  common." 

I  have  more  than  once  found  occasion  to  call  in  question  the  ac- 
curacy of  Malgaigne's  views  in  relation  to  partial  dislocations,  the 
relative  frequency  of  which  he  seems  constantly  disposed  to  greatly 
exaggerate.  We  cannot  see  the  propriety  of  calling  those  cases  par- 
tial dislocations,  in  which  the  head  of  the  bone  has  fairly  left  the  coty- 
loid cavity,  and  mounted  upon  its  margin ;  even  if  it  remains  in  this 
position  without  tearing  the  capsule ;  since  the  articular  surfaces  are 
now  as  completely  separated  as  if  the  capsule  had  given  way,  and  the 
head  of  the  bone  had  escaped  through  the  laceration.  It  is  in  fact  a 
complete  luxation.  But  I  doubt  very  much  whether  the  head  of  the. 
bone  ever  rests  upon  the  margin  of  the  acetabulum  without  tear- 
ing the  capsule,  unless  it  has  previously  undergone  certain  patho- 
logical changes,  such  as  I  have  already  described ;  at  least  I  cannot 
hesitate  to  reject  all  those  examples  in  which  the  head  of  the  femur 
is  supposed  to  rest  upon  the  upper  or  outer  margin  of  the  acetabu- 
lum ;  and  if  I  permit  myself  to  speak  of  incomplete  dislocations  at  all 
in  this  connection,  I  shall  reserve  the  term  for  those  rare  cases  in 
which  the  head  of  the  femur  becomes  engaged  in  the  cotyloid  notch, 
after  breaking  down  the  fibrous  band  which,  in  the  natural  state,  is 
continuous  with  the  rim  of  the  acetabulum. 

Of  this  form  of  dislocation,  I  think  I  have  met  with  two  examples; 
one  of  which  was  in  the  person  of  the  boy  Lower,  already  mentioned, 
whose  thigh  was  reduced  accidentally  by  his  father;  and  the  other 
occurred  in  a  boy  fifteen  years  of  age,  residing  at  that  time  in  Rutland, 
Vermont.  He  was  brought  to  me  on  the  28th  of  May,  1842,  by  Dr. 
Haynes,  of  Rutland,  at  which  time  the  dislocation  had  existed  five 
years.  His  account  of  himself  was  that  in  walking  upon  a  slippery 
floor,  his  left  leg  slid  outwards  and  backwards  in  such  a  manner  as 
that  when  he  feU  it  was  fairly  doubled  under  his  back.  On  the  tenth 
day  following  the  accident,  he  began  to  walk  with  some  help,  and  he 
has  continued  to  walk  ever  since,  but  with  a  manifest  halt.  Three 
months  after  the  injury  was  received,  it  was  first  seen  by  several  sur- 
geons, who  pronounced  it  a  dislocation,  and  attempted  reduction  with- 
out mechanical  aid,  but  were  unsuccessful. 


6Q6  DISLOCATIONS    OF    THE    THIGH. 

When  the  young  man  was  brought  to  me,  the  limb  was  neither 
lengthened  nor  shortened,  but  the  thigh  was  forcibly  abducted  and 
rotated  outwards.  It  could  not  be  flexed  nor  greatly  extended.  The 
head  of  the  femur  could  be  distinctly  felt,  as  it  lay  anterior  to  the 
socket,  but  not  sufficiently  far  forwards  to  rest  upon  the  foramen 
ovale. 

J.  C.  Warren,  of  Boston,  has  reported  a  similar  example  in  a  child 
six  years  old,  who  was  brought  April  21,  1841,  to  the  Massachusetts 
General  Hospital.  Dr.  Hale,  who  saw  the  lad  at  the  end  of  two  weeks, 
thought  it  a  dislocation,  but  it  had  been  treated  by  another  surgeon 
as  a  case  of  hip-disease.  The  dislocation  had  now  existed  eight  or 
ten  weeks.  The  limb  was  a  little  lengthened,  abducted,  turned  out- 
wards, and  advanced  in  front  of  the  body,  with  very  slight  motion  of 
either  flexion  or  extension,  and  almost  no  tenderness  about  the  joint. 
Dr.  Warren,  also,  was  able  to  feel  indistinctly  the  head  of  the  bone 
"immediately  external  to,  and  in  contact  with,  the  insertion  of  the 
triceps  and  gracilis  muscles." 

An  attempt  was  made  by  manual  extension  and  manipulation  to  ac- 
complish the  reduction,  but  without  success.^ 

It  is  probable  that  both  the  above  cases  which  I  have  described 
at  length,  were  examples  of  partial  dislocation ;  yet  I  cannot  conceal 
from  others  a  doubt  which  I  actually  entertain  whether  they  were  not, 
after  all,  only  examples  of  hip-joint  disease,  arrested  after  having 
wrought  certain  slight  pathological  changes  in  the  joint  and  the  tissues 
adjacent.  If,  however,  they  were  not  examples  of  incomplete  dislo- 
cations of  the  hip-joint,  then  I  question  whether  any  such  cases  have 
ever  occurred. 


§  8.  coxo-femoral  dislocations,  complicated  with  fracture  oe  the 

Femur. 

Such  complications  are  exceedingly  rare,  but  it  will  not  do  to  deny 
their  possibility ;  although  in  some  of  the  cases  reported,  the  testimony 
is  not  so  clear  as  not  to  leave  a  doubt  whether  the  surgeons  have  not 
erred  in  their  diagnosis. 

James  Douglas  has  reported  a  case  of  dislocation  upon  the  pubes, 
complicated  with  a  fracture  of  the  neck  of  the  femur,  the  actual  con- 
dition of  which  was  verified  by  an  autopsy  ;  the  patient  having  died 
twelve  years  after  the  injury  was  received.  The  head  of  the  femur 
still  remained  above  the  pubes,  and  was  in  no  way  connected  with  its 
neck  or  shaft.  The  upper  end  of  the  femur  projected  in  the  groin, 
lying  upon  the  inside  of  the  femoral  artery  and  vein.  Many  other 
curious  pathological  changes  had  also  occurred.^ 

The  well-authenticated  examples  of  reduction  of  the  dislocation, 
where  the  femur  was  broken  also,  are  still  more  rare ;  and  several  of 

1  Warren,  Bost.  Med.  and  Surg.  Journ.,  vol.  xxiv.  p  220. 

'^  Amer.  Journ.  Med.  Sci.,  vol.  xxxiii.  p.  455,  from  Lond.  and  Edin.  Month.  Journ. 
of  Med.  Sci.,  Dec.  1843. 


COXO-FEMOEAL    DISLOCATIONS    WITH    FRACTUEE,         667 

the  recorded   examples  which  mj  researches  have  discovered,  need 
additional  confirmation. 

John  Bloxham,  of  Newport,  in  the  Isle  of  Wight,  claims  to  have 
reduced  a  dislocation  of  the  femur  on  the  pubes,  which  was  accom- 
panied with  a  fracture  of  the  thigh  a  little  above  its  middle.  The 
following  is  the  account  of  this  interesting  case  which  we  find  in  the 
London  Medico- Ghirurgical  Beview,  copied  from  the  Medical  Q-azette  oi 
Aug,  24th,  1833.  We  regret  that  we  are  unable  to  see  the  account  as 
published  in  the  Gazette^  which  might  supply  some  circumstances 
important  to  a  full  appreciation  of  the  case: — 

On  the  seventh  or  eighth  day  after  the  accident,  "  the  patient  was 
laid  upon  his  back  on  the  bed  and  kept  in  that  position  by  means  of 
a  sheet  passed  across  the  pelvis,  and  fastened  to  the  bedstead  ;  another 
sheet  was  also  passed  over  the  left  groin,  and  secured  in  a  similar 
manner.  The  dislocated  and  fractured  limb  was  then  inclosed  in 
splints,  one  of  which  extended  up  the  back  of  the  thigh  as  far  as  the 
tuberosity  of  the  ischium.  Pulleys,  which  were  secured  to  a  staple  in 
the  ceiling,  placed  at  the  distance  of  a  foot  to  the  right  of  a  point 
vertical  to  the  patient's  navel,  were  then  attached  to  a  bandage  fastened 
round  the  splints,  as  high  up  as  possible. 

"The  foot  was  raised  with  the  knee  extended,  so  as  to  bring  the  limb 
nearly  to  a  right  angle  with  the  line  of  the  tackle,  when,  by  drawing 
gradually  on  the  cord,  in  the  course  of  about  ten  or  fifteen  minutes, 
the  head  of  the  bone  was  rendered  movable,  and  was  brought  con- 
siderably more  forward.  I  then  began  to  press  on  the  head  of  the 
bone,  so  as  to  push  it  downwards,  whilst  the  pulleys  held  it  partially 
disengaged  from  the  pelvis.  In  a  few  minutes  the  head  of  the  bone 
passed  over  the  ridge  of  the  os  pubis,  and  I  then  directed  the  foot  to 
be  raised  a  little  higher,  which,  by  putting  the  gluteii  muscles  more 
upon  the  stretch,  was  calculated  to  render  them  more  efficient  in 
drawing  the  bone  into  its  proper  place.  By  this  manoeuvre,  the  head 
of  the  bone  was  drawn  backwards,  and  on  the  foot  being  more  elevated 
and  the  cord  slackened,  it  continued  to  recede  from  my  fingers  till  the 
trochanter  major  made  its  appearance  in  the  natural  situation,  and  the 
reduction  was  found  to  be  perfectly  complete, 

"Lest  the  head  of  the  bone  should  slip  backwards  on  the  dorsum  ilii, 
I  directed  an  assistant  to  apply  firm  pressure  during  the  latter  part  of 
the  process,  above  and  behind  the  acetabulum. 

"  The  apparatus  was  then  removed,  the  thigh  bound  up  in  short 
splints,  and  the  patient  laid  upon  a  double  inclined  plane.  No  symp- 
toms of  inflammation  appeared  afterwards  about  the  joint.  Passive 
motion  was  employed  at  the  end  of  a  week,  and  occasionally  repeated 
during  the  whole  reparatory  process."^ 

Without  intending  to  question  the  accuracy  of  the  statements  in 
this  case,  which,  in  the  main,  seem  to  bear  the  marks  of  credibility, 
we  must  express  our  surprise  that  so  little  difficulty  was  experienced 
in  the  reduction,  if  the  femur  was  actually  broken,  no  more,  indeed, 
than  is  usually  experienced  when  the  bone  is  not  broken  ;  and  that  Mr. 

'  Lond.  Med,-Chir.  Rev.,  vol,  xix,  p,  4^0,  Oct.  1833. 


668  DISLOCATIONS    OF    THE    THIGH. 

Bloxham  was  able  to  employ  safely  passive  motion  at  the  end  of  a 
week. 

Charles  Thorahill  relates,  in  the  London  Medical  Gazette  for  July, 
1836,  a  case  of  fracture  of  the  femur  through  its  upper  third,  in  a  man 
set.  40,  with  dislocation  into  the  ischiatic  notch ;  which  dislocation,  he 
assures  us,  was  reduced  at  the  end  of  six  weeks.  But  it  is  much  more 
probable  that,  instead  of  reducing  a  dislocation,  he  refractured  the 
bone.  During  more  than  one  hour  and  a  half,  aided  by  pulleys, 
tractions  and  manipulations  were  made  in  almost  every  direction! 
The  upper  part  of  the  thigh  was  lifted  with  all  the  strength  of  one 
man  by  means  of  a  jack  towel ;  it  was  violently  rotated,  adducted, 
and  abducted.  Both  the  perineal  and  the  knee  band  gave  way,  from 
the  excess  of  the  force  employed ;  and,  finally,  the  head  of  the  femur 
resumed  its  place  with  an  audible  crash.  Alter  which  the  "limb  was 
of  nearly  equal  length  with  the  other;"  but  there  remained  an  "im- 
mense deposit"  around  the  acetabulum.' 

Malgaigne  says  that  M.  Eteve  found  a  poor  fellow  with  a  dislocation 
of  his  left  thigh  backwards,  a  fracture  near  its  middle,  a  penetrating 
wound  of  the  knee,  and  a  fracture  of  the  fibula  in  the  same  leg. 
Without  delay  he  proceeded  to  reduce  the  dislocation  by  directing 
two  assistants  to  support  the  body,  three  to  support  the  leg,  and  two 
more  to  make  extension  from  a  towel  tied  not  very  tightly  around  the 
thigh  above  the  fracture.  The  leg  was  then  extended  upon  the  thigh 
and  the  thigh  flexed  upon  the  pelvis  until  it  was  at  a  right  angle  wilh 
the  body;  and  after  a  gradual  extension  had  been  made  in  thTs  direc- 
tion, M.  Etdve  pushed  with  all  his  strength  the  head  of  the  bone  into 
its  socket.  Of  which  case,  Malgaigne  justly  remarks,  that  the  "  exten- 
sion" practiced  by  the  surgeon  was  only  imaginary.^^  If  the  reduction 
was  accomplished  at  all,  it  was  by  manipulation  and  pressure. 

Finally,  Markoe  relates  in  the  paper  to  which  we  have  already 
several  times  made  allusion,  the  case  of  a  boy  set.  8,  who  was  admitted 
into  the  New  York  City  Hospital  on  the  29th  of  June,  1853,  with  a 
compound  fracture  of  the  right  thigh,  a  simple  fracture  of  the  left,  and 
a  dislocation  of  the  head  of  the  right  femur  upwards  and  backwards 
upon  the  dorsum  ilii. 

When  placed  upon  the  bed,  the  right  limb  lay  obliquely  across  the 
abdomen  of  the  boy,  with  the  foot  resting  against  the  axilla  of  the 
left  side.  "  The  house-surgeon,  to  whose  care  the  case  fell  on  admis- 
sion, took  the  injured  limb  in  his  hands  and  very  carefully  carried  it 
over  the  abdomen  to  the  right  side,  and  then  adducted  it  and  brought 
It  down  toward  the  straight  position,"  during  which  procedure  the 
head  of  the  bone  is  supposed  to  have  resumed  its  place  in  the  socket.^ 
Such  is  the  account  furnished  of  the  symptoms  and  treatment  of 
this  extraordinary  case;  too  meagre  certainly  to  entitle  it  to  much 
confidence,  or  to  permit  us  to  draw  from  it  any  practical  inferences. 
We  are  not  even  informed  what  was  the  name  of  the  young  man  who 

'  Amer.  Journ.  Med.  Sci.,  vol.  xxv.  p.  218. 

2  Malgaigne,  op.  cit.,  torn.  li.  p.  2G6 ;  from  Gazette  Med.,  1838,  p.  751. 

'^  New  York  Journ.  Med.,  Jan.  1855,  p.  30. 


DISLOCATIONS    OF    THE    PATELLA    OUTWAEDS.  669 

alone  saw  and  treated  the  case,  nor  what  was  his  responsibility  as  a 
surgeon. 

I  have  been  unable  to  find  any  other  examples  of  fracture  of  the 
femur  complicated  with  dislocation;  and,  rejecting  at  least  Mr.  Thorn- 
hill's  case  as  altogether  incredible,  the  proper  conclusion  would  be, 
that  reduction  is  sometimes  possible  in  recent  cases,  if  the  surgeon 
will  resort  promptly,  before  swelling  and  muscular  contraction  have 
taken  place,  to  manipulation  conjbined  with  pressure  upon  the  head 
of  the  bone.  Indeed,  it  is  probable  that  pressure  alone  is  the  means 
upon  which  the  success  will  finally  depend.  Eichet  says  that  he 
has  several  times  dislocated  the  femur  in  the  cadaver;  and  then 
having  sawn  off  the  head  so  as  to  represent  a  fracture,  he  has  always 
been  able  to  push  the  head  of  the  bone  easily  into  its  socket.^  By 
seizing  the  moment  then  when  the  patient  is  laboring  under  the  shock, 
or  by  placing  hira  completely  under  the  influence  of  an  anaesthetic, 
no  resistance  will  be  offered  by  the  muscles  any  more  than  in  the 
cadaver,  and  the  reduction  may,  perhaps,  be  as  easily  effected. 

I  have  no  confidence  that  anything  can  be  accomplished  by  exten- 
sion; nor  do  I  think  it  will  be  best  to  wait  until  the  femur  has  united, 
since  such  delay  will  probably  render  the  reduction  impossible. 


CHAPTER    XVII. 

DISLOCATIONS   OF  THE  PATELLA, 

§  1.  Dislocations  or  the  Patella  Outwards. 

Causes. — In  the  majority  of  cases  it  has  been  occasioned  by  muscular 
action  ;  and  especially  is  this  liable  to  occur  in  persons  who  are  knock- 
kneed,  or  whose  external  condyles  have  not  the  usual  prominence 
anteriorly.  It  may  be  caused  by  suddenly  twisting  the  thigh  inwards 
while  the  weight  of  the  body  rests  upon  the  foot,  and  the  leg  is  thus 
kept  turned  outwards;  or  by  falling  with  the  knee  turned  inwards  and 
the  foot  outwards.  Occasionally  it  is  the  result  of  a  blow  received 
upon  the  inside,  or  upon  the  front  and  inner  margin  of  the  patella. 
In  some  persons  there  seems  to  exist  a  preternatural  laxity  of  the  liga- 
mentum  patellge  or  of  the  tendon  of  the  quadriceps  extensor  which 
exposes  the  subject  to  this  accident  from  very  trifling  causes.  Fer- 
gusson  says  he  has  known  it  to  be  occasioned  by  a  child's  stepping 
upon  the  knee  of  a  person  lying  in  bed  :  and  Skey  says  he  has  seen 
two  cases  which  occurred  spontaneously  during  sleep.     B.  Cooper 

1  New  York  Journ,  Med,,  Marcli,  1854,  p.  293;  from  Bullet,  de  Ther. 


670 


DISLOCATIONS    OF    THE    PATELLA. 


Fig.  273. 


has  seen  a  young  lady  who  frequently  dislocated  her  patella  outwards 
by  merely  striking  her  toe  against  the  carpet,  or  in  dancing.  Boyer, 
Sir  Astley  Cooper,  and  others,  mention  similar  examples. 

Pathological  Anatomy. — Most  frequently  the  dislocation  is  only  par- 
tial, the  inner  half  of  the  patella  resting  upon  the  articular  surface  of 
the  outer  condyle ;  and  in  consequence  of  the  peculiar  obliquity  of 
these  surfaces,  together  with  the  action  of  the  vasti  and  rectus  femoris, 
the  outer  margin  of  the  patella  becomes  tilted  forwards. 

If  the  dislocation  is  more  complete,  this  margin  begins  to  fall  over 
backwards,  as  in  the  accompanying  drawing;  and  in  more  extreme 
cases  the  patella  lies  flat  upon  the  outer  side  of  the 
condyle,  with  its  inner  margin  directed  forwards. 

When  the  dislocation  is  partial,  it  is  probable  that 
neither  the  capsule  nor  the  ligamentum  patellge  usu- 
ally suffers  much  laceration  ;  but  in  complete  disloca- 
tions, the  capsule  at  least  must  have  given  way  more 
or  less.  Norris,  of  Philadelphia,  reports  a  case  of 
partial  luxation  in  which  the  complications  were 
more  serious.  John  Scanlin,  ast.  32,  was  admitted 
to  the  Pennsylvania  Hospital,  on  the  27th  of  August, 
1839,  in  consequence  of  injuries  received  a  short 
time  previous  by  having  become  entangled  in  ma- 
chinery. In  addition  to  several  fractures  in  other 
limbs,  he  was  found  to  have  a  subluxation  of  his 
left  patella  outwards,  its  outer  edge  being  much 
raised  and  resting  on  the  side  of  the  external  condyle 
of  the  femur,  while  its  inner  edge  was  depressed,  and 
firmly  fixed  in  the  hollow  between  the  condyles. 
The  internal  lateral  ligament  of  the  knee  was  rup- 
tured, allowing  the  head  of  the  tibia  to  be  moved 
considerably  outwards.  A  depression  existed,  also, 
between  the  tubercle  of  the  tibia  and  the  lower  end  of  the  patella,  at 
the  middle  and  inner  side  of  the  knee,  evidently  produced  by  a  rup- 
ture of  the  ligamentum  patella  in  nearly  its  whole  extent.  There 
was  almost  no  swelling,  and  the  limb  was  moderately  flexed.  By 
firm  pressure  the  patella  could  be  restored  to  position,  but  as  soon  as 
the  hand  was  removed  it  returned  to  its  original  position.  At  the  end 
of  two  months  "a  good  degree  of  motion  existed  at  the  knee-joint, 
which  was  in  no  way  inflamed  or  painful."^ 

Symptoms. — The  limb  is  slightly  bent,  but  immovable;  the  breadth 
of  the  knee  is  considerably  increased;  the  inner  condyle  projects  un- 
naturally, and  the  patella  is  distinctly  felt  upon  the  outer  side.  If  the 
dislocation  is  partial,  the  outer  margin  of  the  patella  forms  an 
irregular  sharp  ridge  in  front  of  the  external  condyle.  If  it  is  com- 
plete, the  inner  margin  presents  itself  in  front  of  the  external  condyle, 
and  the  outer  margin  looks  backwards.  Usually  the  patient  suffers 
great  pain  so  long  as  the  dislocation  remains  unreduced, 

Watson,  of  New  York,  saw  a  case  of  complete  dislocation  of  the 


Dislocation  of  the  pa 
tella  outwards. 


'  Norris,  Amer.  Journ.  Med.  Sci.,  vol.  xxv.,  Feb.  1840,  p.  276. 


DISLOCATIONS    OF    THE    PATELLA    OUTWARDS.  671 

patella  outwards  in  a  fat  young  lady,  witli  lax  fibre,  and  occasioned 
by  dancing.  He  says  the  knee  was  slightly  but  firmly  flexed.  It 
was  reduced  by  a  very  slight  pressure  with  the  fingers,  and  although 
some  inflammation  with  effusion  into  the  joint  ensued,  the  use  of  the 
limb  was  completely  restored  in  a  week  or  ten  days,^ 

Prognosis. — Eeduction  is  in  general  easily  accomplished,  but  a  re- 
luxation  is  very  prone  to  occur.  In  the  few  examples  reported  of  a 
permanent  luxation,  the  patients  have  eventually  recovered  the  use  of 
the  limb  in  a  great  measure.  Boyer  saw  four  cases  of  this  kind,  in 
three  of  which  it  existed  in  the  left  leg  and  had  remained  from  infancy. 
The  patellae  were  easily  replaced,  but  unless  confined  they  soon 
became  displaced  again ;  not  one  of  thera  found  it  necessary  to  apply 
for  surgical  aid,  as  "they  suffered  no  great  inconvenience  from  the 
luxation,  and  it  exempted  them  from  military  service." 

After  reduction,  very  little  or  no  inflammation  usually  follows. 
Mr,  Key  has,  however,  narrated  a  case  in  Guyh  Hospital  Reports^  of 
death  from  suppuration  in  the  knee-joint,  following  upon  the  reduction 
of  an  inward  subluxation.  The  dislocation  was  produced  by  a  fall 
while  carrying  a  pail,  and  was  reduced  by  very  gentle  pressure;  but 
the  patient,  a  girl,  ^t.  20,  although  apparently  in  good  health,  was 
believed  to  be  somewhat  strumous.^ 

Treatment. — In  order  to  relax  completely  the  quadriceps  extensor, 
by  whose  action  chiefly  the  patella  is  held  in  its  unnatural  position, 
the  body  should  be  bent  forwards,  while  at  the  same  moment  the  leg 
is  extended  upon  the  thigh  and  the  thigh  flexed  upon  the  body.  The 
surgeon  will  accomplish  these  indications  in  the  most  simple  manner, 
by  placing  the  patient  in  a  chair,  and  then  lifting  the  foot  upon  his 
own  shoulder,  as  he  kneels  or  sits  before  him.  Sometimes  the  patella 
will  resume  its  position  at  once  when  this  manoeuvre  is  adopted ;  but 
if  it  does  not,  slight  lateral  pressure,  made  with  the  fingers,  will  gene- 
rally be  found  sufficient  to  accomplish  the  reduction. 

In  some  instances,  where  other  means  have  failed,  the  reduction  has 
been  effected  by  violent  flexion  and  extension  of  the  knee,  aided  by 
lateral  pressure. 

I  have  already  mentioned,  when  speaking  of  dislocations  into  the 
foramen  thyroideum,  the  case  of  N.  Smith,  in  whose  person  I  found 
at  the  same  moment  a  dislocation  of  the  thigh,  a  subluxation  outwards 
of  the  tibia,  and  a  complete  outward  luxation  of  the  corresponding 
patella.  This  was  occasioned  by  a  fall  from  a  height  upon  the  inside 
of  the  knee,  I  reduced  the  tibia  first,  and  then  easily  replaced  the 
patella  by  lifting  the  leg  and  pushing  with  my  fingers  against  its  outer 
margin. 

In  many  cases  the  patients  themselves  have  reduced  the  dislocation 
immediately,  and  the  surgeon  is  only  consulted  in  relation  to  the  after 
treatment.  Liston  says  that  this  is  so  constantly  the  fact  or  else  such 
dislocations  are  really  so  rare  that  it  has  never  happened  to  him  to 
have  an  opportunity  of  reducing  any  form  of  dislocation  of  the  patella. 

Not  long  since  a  young  gentleman  aet.  25,  residing  in  Somerset,  N.  Y., 

'  Watson,  New  York  Journ.  Med.,  vol.  i.  p.  306.  ^  Op.  cit.,  voL  i.  p.  260. 


672  DISLOCATIONS    OF    THE    PATELLA. 

called  upon  me  in  consequence  of  having  discovered  a  floating  carti- 
lage in  his  knee-joint.  His  account  of  the  matter  was  that  on  the  first 
of  February,  1858,  he  was  kicked  by  a  cow  upon  the  outside  of  the 
right  leg  about  six  inches  below  the  knee,  and  that  he  immediately 
found  the  patella  dislocated  outwards.  After  several  efforts  he  finally 
succeeded  in  reducing  it  himself.  His  knee  soon  became  greatly 
swollen,  so  that  for  five  weeks  he  was  unable  to  walk,  and  he  has  been 
more  or  less  lame  to  this  time.  Six  months  after  the  accident  he  dis- 
covered a  floating  cartilage  on  the  inside  of  the  patella  about  one  inch 
in  diameter,  which  occasionally  slips  between  the  joint  surfaces,  and 
suddenly  trips  him  up. 


§  2.  Dislocations  op  the  Patella  Inwards. 

Causes. — Less  frequent  than  dislocations  outwards,  they  are  occa- 
sioned generally  by  direct  blows  received  upon  the  outer  margin  of  the 
patella. 

Fig.  274. 


Dislocation  of  the  patella  inwards. 


The  symptoms,  pathological  anatomy,  and  treatment  will  be  the 
same  as  in  dislocations  outwards,  except  so  far  as  these  must  necessarily 
vary  from  the  opposite  position  of  the  patella. 


§  3.  Dislocations  of  the  Patella  upon  its  Axis. 

Syn. — "  Semi-rotation ;"  Miller. 

These  accidents,  of  which  up  to  the  present  moment  not  more  than 
fifteen  examples  have  been  recorded,  seem  to  be  the  result  of  the  same 
causes  which  produce  lateral  luxations;  and  indeed  they  may  be  re- 
garded as  only  exaggerated  forms  of  incomplete  lateral  dislocations. 
In  these  latter  accidents,  as  we  have  already  noticed,  the  external  or 


DISLOCATION'S    OF    THE    PATELLA    UPON    ITS    AXIS.        673 

the  internal  margin  of  the  patella,  according  as  the  subluxation  is  to 
the  outer  or  inner  side,  is  thrown  more  or  less  obliquely  forwards;  a 
position  into  which  it  is  carried  partly  by  the  peculiar  form  of  the 
articulating  surfaces,  and  partly  by  the  action  of  the  vasti  and  rectus 
femoris  muscles.  If  now  these  muscles  were  to  contract  suddenly 
and  violently,  and  the  return  of  the  patella  to  its  normal  position  was 
prevented  by  the  lodgment  of  one  of  its  margins  in  the  inter-condylo- 
idean  fossa,  the  other  or  free  margin  would  be  compelled  to  rise  until 
it  became  perpendicular  to  the  limb,  or  it  might  perhaps  even  become 
completely  reversed  in  its  socket.  The  signs  of  this  accident  are  such 
as  to  render  an  error  in  the  diagnosis  almost  impossible.  The  limb 
is  generally  found  forcibly  extended,  occasionally  it  is  in  a  position 
of  moderate  flexion,  but  the  projection  of  the  sharp  border  of  the 
patella  directly  forwards  under  the  skin,  is  itself  sufficient  to  deter- 
mine the  true  nature  of  the  injury. 

Reduction  may  be  effected  by  the  same  manoeuvres  which  we  have 
recommended  in  lateral  luxations ;  but  if  these  measures  do  not  suc- 
ceed, we  may  direct  the  patient  to  make  a  violent  effort  himself  to 
flex  and  extend  the  limb,  or  the  surgeon  may  force  the  limb  into 
flexion  and  extension  alternately,  or  he  may  rotate  the  tibia  upon  the 
femur,  and  then  flex.  Finally,  he  ought  to  make  use  of  lateral  pres- 
sure also,  upon  both  margins  of  the  upright  patella,  but  in  opposite 
directions. 

Watson,  of  New  York,  has  related  the  following  example  of  rota- 
tion of  the  patella  upon  its  inner  margin  ("  Luxation  Yerticale  Externe," 
Malrj). 

Henry  Burton,  aged  about  thirty-five  years,  of  rather  slender  frame, 
while  riding  on  horseback  in  a  crowd,  received  a  blow  upon  his  knee 
from  a  horse  ridden  by  another  person.  When  seen  by  Dr.  Watson, 
soon  after  the  accident,  the  leg  was  perfectly  straight,  but  could  be 
flexed  to  about  an  angle  of  140°  without  causing  pain.  "  The  patella 
appeared  to  be  slightly  drawn  up,  and  it  was  twisted  upon  its  axis, 
presenting  its  outer  edge,  in  a  prominent  hard  line,  in  front  of  the 
knee;  its  inner  edge  was  resting  either  in  the  groove  between  the 
condyles  of  the  femur,  upon  which  its  posterior  face  should  naturally 
play,  or  in  the  small  depression  on  the  anterior  face  of  the  femur, 
immediately  above  this  groove.  The  anterior  surface  of  the  patella 
was  turned  inwards,  its  posterior  surface  outwards,  and  it  rested  nearly 
at  right  angles  with  its  natural  position.  Its  upper  and  lower  attach- 
ments were  both  preserved,  and  could  be  distinctly  felt ;  and  a  sort  of 
band  appeared  to  pass  from  its  under,  or,  as  it  now  lay,  its  outer  face, 
inwards  to  the  deeper  portion  of  the  knee-joint.  This  band,  as  I  con- 
ceived, was  caused  either  by  the  tension  of  the  capsular  ligament,  or 
by  the  rupture  of  its  edge,  as  it  passes  from  the  outer  side  of  the 
patella.  The  position  of  the  bone  was  so  well  marked  that  no  one  at 
all  acquainted  with  the  anatomy  of  the  part  could  mistake  the  nature 
of  the  accident. 

"  With  the  leg  extended,  and  the  anterior  muscles  of  the  thigh 
forced  downwards  as  much  as  possible,  pressure  was  made  upon  the 
patella  with  the  expectation  of  forcing  down  its  prominent  edge.     The 
43 


674  DISLOCATIONS    OF    THE    PATELLA. 

effort  was  followed  only  by  an  increase  of  pain,  the  bone  remaining 
permanently  fixed.  Another  attempt  was  made  to  cant  its  posterior 
edge  inwards,  and  to  bring  its  anterior  edge  outwards,  without  pressing 
it  against  the  condyles  of  the  femur,  by  forcing  the  head  of  a  key 
against  the  posterior,  now  the  outer  face  of  the  patella  (using  this  as  a 
fulcrum),  and  pressing  the  prominent  edge  of  the  bone  toward  the 
outer  condyle.  This  manoeuvre  gave  him  no  pain,  but  was  as  fruit- 
less in  its  result  as  the  other.  At  length  the  knee  was  forcibly  bent 
and  immediately  straightened  again ;  and  then  by  canting  the  patella  as 
before,  and  pushing  it  slightly  downwards  and  inwards,  it  sprung  with 
a  sudden  snap  into  its  proper  position."^ 

Dr.  Joseph  P.  Gazzam,  of  Pittsburg,  Pa.,  has  met  with  a  similar 
case.  On  the  10th  of  Sept.,  1842,  James  Porter  was  thrown  while 
wrestling,  and  immediately  found  himself  unable  to  rise.  Dr.  Gazzam 
saw  him  about  an  hour  after  the  accident,  and  found  the  patella  of 
the  right  leg  dislocated  on  its  axis,  and  resting  on  its  inner  edge  in 
the  groove  between  the  condyles  of  the  femur.  Dr.  G.  proceeded  to 
attempt  reduction,  but  failed,  after  having  made  repeated  trials  by 
lifting  the  limb  toward  the  body  and  by  pressure  in  opposite  direc- 
tions. In  consultation  with  Dr.  Addison,  it  was  now  determined  to 
divide  the  ligamentum  patellae,  which  was  done  by  introducing 
beneath  the  skin  a  narrow-bladed  knife,  and  cutting  close  to  the 
tubercle  of  the  tibia.  Again  the  attempts  at  reduction  were  renewed, 
but  .without  success.  The  patella  could  be  moved  on  its  edge  more 
freely  than  before  the  cutting,  but  resisted  every  effort  to  replace  it. 
The  patient  was  now  bled  in  the  erect  posture  and  until  the  approach 
of  syncope,  but  to  no  purpose.  On  the  following  morning,  it  was 
determined  to  adopt,  with  some  modification,  the  mode  practiced  so 
successfully  by  Dr.  Watson.  "  The  thigh  was  strongly  flexed,"  says 
Dr.  Gazzam,  "  on  the  pelvis,  and  the  heel  elevated.  Then  the  leg  was 
flexed  steadily  and  forcibly  on  the  thigh,  and  suddenly  straightened. 
At  the  moment  of  straightening  the  leg,  I  pressed  very  strongly 
against  the  lower  edge  of  the  patella  from  without,  with  the  head  of  a 
door  key  well  wrapped,  while  Dr.  Addison  pressed  with  both  thumbs 
against  the  upper  edge  of  the  bone  toward  the  external  condyle.  On 
the  fourth  trial  this  manoeuvre  succeeded,  the  bone  springing  into  its 
place  with  a  snap."  Recovery  was  uninterrupted,  and  two  or  three 
months  after,  the  patient  had  the  complete  use  of  his  limb.^ 

In  a  case  of  the  same  kind,  published  originally  in  Busies  Magazine, 
and  which  is  copied  at  length  by  Mr.  B.  Cooper  in  his  edition  of  Sir 
Astley's  great  work,  the  reduction  was  found  impossible,  notwithstand- 
ing the  surgeon  finally  had  the  temerity  to  sever  completely  the  ten- 
don of  the  quadriceps  extensor,  and  the  ligamentum  patella.  Exten- 
sive suppuration  followed,  under  which  the  poor  fellow  finally  sank 
and  died. 

It  is  scarcely  necessary  to  say  that,  rather  than  expose  the  patient 
to  such  hazards,  it  would  be  better  to  leave  the  bone  unreduced. 

'  Watson,  New  York  Journ.  Med.,  Oct.  1839,  p.  302. 

^  Grazzam,  Amer.  Journ.  Med.  Sci.,  vol.  xxxi.  April,  1843,  p.  363. 


DISLOCATION'S    OF    THE    HEAD    OF    THE    TIBIA.  675 


§  4.  Dislocations  or  the  Patella  Upwards. 

Occasioually  the  ligamentura  patella  has  been  found  so  much  elon- 
gated and  relaxed,  as  topermit  the  patella  to  glide  upwards  upon  the 
front  of  the  femur.  Heister  and  Eavaton  have  each  seen  an  example 
in  which  a  displacement  from  this  cause  existed  to  the  extent  of  three 
inches.  It  is  much  more  common,  however,  to  meet  with  this  dislo- 
cation as  a  result  of  a  rupture  of  the  ligamentum  patellse,  as  the  fol 
lowing  example  will  illustrate. 

On  the  ISth  of  Dec.  1850,  Dennis  Mullards,  set.  50,  was  admitted 
to  the  surgical  wards  of  the  Buffalo  Hospital  of  the  Sisters  of  Charity. 
While  at  work  on  this  same  day,  he  had  slipped  and  fallen,  with  his 
knee  forcibly  flexed  under  his  body.  I  found  the  ligament  of  the 
patella  torn  asunder  and  the  patella  drawn  up  two  or  three  inches 
upon  the  front  of  the  thigh.  We  applied  at  once  the  dressings  used 
by  me  for  a  broken  patella,  and  were  able  to  bring  the  bone  down 
completely  to  its  place.  Three  weeks  from  the  time  of  the  receipt  of 
the  injury,  the  dressings  were  removed,  and  the  patella  was  found  to 
be  nearly  but  not  quite  in  its  original  place.  From  this  time  we  com- 
menced to  move  the  joint :  in  about  ten  daj^s  more  he  left  the  hospital, 
and  I  lost  sight  of  him,  so  that  I  am  unable  to  speak  more  definitely 
of  the  result. 


CHAPTER    XVIII. 

DISLOCATIONS    OF   THE   HEAD    OF   THE    TIBIA. 

Syn. — "  Tibia  upon  the  femur:"  "dislocations  of  the  leg." 

In  consequence  of  the  great  size  and  irregularity  of  the  articular 
surfaces  between  the  tibia  and  femur,  together  with  the  remarkable 
number  and  strength  of  the  ligaments  which  bind  the  two  bones  to- 
gether, dislocations  at  this  joint  are  exceedingly  rare.  They  are 
known  to  take  place,  however,  in  four  principal  directions,  namely, 
backwards,  forwards,  inwards,  and  outwards.  A  dislocation  may  also 
occur  in  either  of  the  diagonals  between  these  points,  that  is,  antero- 
laterally,  or  postero-laterally.  They  may  be  either  complete  or  incom- 
plete. Velpeau  has  found  upon  record  thirteen  examples  of  complete 
dislocations  forwards,  and  eight  backwards,  but  not  one  of  a  complete 
lateral  luxation.  Velpeau  thought  also  that  the  antero-posterior  lux- 
ations were  always  complete,  but  Malgaigne  has  shown  that  this  opin- 
ion is  erroneous. 

Simple  flexion  and  extension,  however  extreme,  are  generally  in- 
sufficient to  produce  either  of  these  dislocations.  They  may  be  pro- 
duced by  a  violent  blow  upon  the  lower  end  of  the  femur,  or  upon 


676 


DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA. 


the  upper  end  of  the  tibia,  or  by  twisting  the  tibia  upon  the  femur,  as 
when  the  foot  is  made  fast  in  a  hole,  and  the  body  swings  around  upon 
the  knee. 


Fig  275. 


§  1.  Dislocations  of  the  Head  op  the  Tibia  Backwards. 

Symptoms. — The  head  of  the  tibia  is  felt  in  the  popliteal  space ;  and, 
if  the  dislocation  is  complete,  the  pressure  upon  the  popliteal  nerve 
becomes  excessively  painful. 

A  marked  depression  exists  in  front,  imme- 
diately below  the  patella,  and  especially  upon 
the  sides  of  the  ligamentum  patellae ;  the  con- 
dyles of  the  femur  project  strongly  in  front;  the 
leg  may  be  not  at  all,  or  only  slightly  shortened, 
or  the  shortening  may  amount  to  one  inch  or 
more,  and  usually  it  is  in  a  position  of  extreme 
extension,  or  thrown  forwards  from  the  line  of 
the  axis  of  the  femur ;  but  its  position  has  been 
found  to  vary  greatly  in  different  cases,  the  limb 
being  sometimes  very  much  flexed,  and  in  others 
very  slightly  flexed,  or  perfectly  straight. 

Pathological  Anatom,y. — The  posterior  ligament 
of  the  joint  is  torn ;  the  muscles  of  the  ham 
are  put  upon  the  stretch ;  the  popliteal  nerves 
and  vessels  compressed ;  and  the  head  of  the 
tibia  either  rests  partly  upon  the  posterior  half 
of  the  lower  articulating  surface  of  the  femur, 
or  it  passes  up  and  rests  only  against  its  pos- 
terior articulating  surface,  which  in  this  direc- 
tion extends  an  inch  or  more  upwards.  If  the  dislocation  is  complete, 
the  crucial  ligaments  are  also  torn,  and  all  the  parts  about  the  joint 
sufi'er  extensive  injury  from  stretching,  laceration,  or  compression. 

Prognosis. — Malgaigne  has  seen  three  examples  of  incomplete  back- 
ward taxations  which  were  not  reduced,  and  neither  of  the  persons 
were  very  greatly  maimed  in  consequence.  One  walked  with  crutches 
after  three  or  four  days,  and  with  a  cane  after  about  five  weeks. 
Another  did  not  leave  his  bed  under  one  month,  and  it  was  nearly 
one  year  before  he  could  lay  aside  his  crutches ;  but  both  of  them 
were  finally  able  to  walk  at  least  twelve  leagues  per  day.  Malgaigne 
informs  us,  however,  that  in  a  similar  case  seen  by  Lassus,  the  patient 
was  confined  to  his  bed  two  years,  although  he  finally  recovered  a 
tolerable  use  of  his  limb. 

If  the  reduction  is  promptly  effected,  the  limb  kept  perfectly  quiet 
a  sufficient  length  of  time,  and  in  other  respects  properly  managed, 
not  much  inflammation  need  generally  to  be  anticipated,  and  the  limb 
may  suffer  in  the  end  very  little,  if  any  maiming. 

Treatment. — It  will  be  proper,  at  first,  to  attempt  the  reduction  by 
simple  manipulation,  as  this  is  often  found  to  succeed  when  the  dis- 
location is  recent  and  incomplete,  and  especially  when  the  system  is 


Dislocation  of  the  head  of  the 
tibia  backwards. 


DISLOCATIONS    OF    HEAD    OF    TIBIA    BACKTVAEDS.  677 

greatly  depressed  by  the  shock  of  the  injury.  If  the  dislocation  is 
complete,  however,  we  can  hardly  anticipate  success  without  the  ap- 
plication of  some  extending  force. 

In  the  employment  of  manipulation  we  ought  to  be  governed  at 
first  by  the  same  rule  which  we  have  found  so  generally  applicable  in 
dislocations  of  the  femur,  namely,  to  carry  the  limb  in  those  directions 
in  which  it  will  move  easily,  or  without  much  force.  If  this  fails,  we 
may  at  once  resort  to  forced  flexion  alternating  with  extension,  rotat- 
ing or  rocking  the  limb  also  occasionally  from  one  side  to  the  other, 
while  at  the  same  moment  strong  pressure  is  made  upon  the  project- 
ing bones  at  the  knee-joint  in  opposite  directions  or  in  the  direction 
of  the  articulation. 

Finally,  it  may  be  necessary  to  resort  to  extension,  made  by  means 
of  a  lacq,  or  by  the  hands  of  strong  assistants,  above  the  ankle, 
always  at  first  in  the  direction  of  the  axis  of  the  tibia;  the  counter- 
extending  band  being  applied  to  the  perineum,  if  the  leg  is  straight, 
but  to  the  lower  and  under  part  of  the  thigh,  if  the  leg  is  flexed. 

A  very  convenient  mode  of  making  extension  where  we  wish  to 
apply  more  than  usual  force,  is  to  lay  the  whole  limb  over  a  firm  double 
inclined  plane,  or  fracture  splint,  securing  the  thigh  to  the  thigh-piece 
with  a  roller,  and  making  the  extension  with  the  screw  attached  to 
the  foot-board.  This  method,  however,  while  it  enables  us  to  use 
great  force  in  the  extension,  prevents  the  surgeon  from  employing,  at 
the  same  time,  those  flexions,  extensions,  and  other  manipulations, 
upon  which  success  so  often  depends. 

Mr.  Eose  has  related  in  the  Provincial  Medical  Journal  of  June  11th, 
1812,  a  characteristic  example  of  this  accident,  except  that  the  patella 
had  also  suffered  a  lateral  displacement,  presenting  the  usual  favora- 
ble termination. 

A  woman  was  standing  upon  a  low  ladder,  when  a  carriage  driven 
furiously  came  in  contact  with  it,  and  precipitated  her  to  the  ground. 
Dr.  Eose,  who  saw  her  almost  immediately,  found  the  tibia  completely 
dislocated  at  the  knee,  the  head  being  driven  behind  the  condyles  of 
the  femur  into  the  ham,  with  the  patella  thrown  to  the  outside  of  the 
external  condyle,  and  the  leg  in  a  state  of  fixed  extension.  Immedi- 
ately, and  without  difficulty,  the  bones  were  restored  by  applying  one 
hand  to  the  patella,  the  other  to  the  back  of  the  upper  portion  of  the 
tibia,  and  simultaneously  pulling  and  pushing  those  bones  toward  their 
natural  positions.  The  patient  was  then  removed  to  a  bed,  and  by 
the  diligent  use  of  antiphlogistic  remedies  inflammation  was  kept  in 
check,  and  the  case  reached  a  favorable  termination  without  one  un- 
toward symptom.  After  the  lapse  of  only  a  few  weeks,  she  had  com- 
pletely recovered  the  use  of  the  knee  joint.^ 

Dr.  Walsham  communicated  a  case  to  Sir  Astley  Cooper,  in  which 
the  dislocation  was  not  only  complete,  but  the  tendon  of  the  quadriceps 
extensor  was  ruptured.  The  leg  was  bent  forwards.  The  reduction 
was  accomplished  very  easily  by  extension  made  with  the  hands  by 
four  men,  in  the  line  of  the  axis  of  the  limb.     In  about  one  month 

'  Eose,  Amer.  Journ.  Med.  Sci.,  vol.  sssi.  p.  216. 


678 


DISLOCATIONS    OP    THE    HEAD    OF    THE    TIBIA. 


this  man  began  to  walk  with  crutches,  but  he  was  not  perfectly  re- 
covered until  after  five  months ;  at  which  time  the  crutches  were 
finally  laid  aside.^ 

8  2.  Dislocations  op  the  Head  of  the  Tibia  Forwards. 


Fig.  276. 


The  signs  of  this  accident  are  the  reverse  of  those  which  belong  to 
dislocations  backwards.     The  patella,  tibia,  and  fibula,  are  prominent 

in  front,  while  the  condyles  of  the  femur 
may  be  felt  behind,  pressing  strongly  upon 
the  muscles,  nerves,  and  bloodvessels  which 
occupy  the  popliteal  space.  In  case  the 
dislocation  is  complete,  a  shortening  may 
exist  to  the  extent  of  one  or  even  three 
inches.  Dr.  O'Beirne,  of  Dublin,  has  men- 
tioned a  case  to  Mr.  B.  Cooper,  in  which 
the  shortening  was  three  inches  and  a  half, 
and  Mr.  Mayo  has  seen  one  example  in 
which  the  dislocated  limb  was  "  fully  four 
inches"  shorter  than  the  other.^  It  is  quite 
probable,  however,  that  these  latter  state- 
ments are  somewhat  exaggerated. 

In  consequence  of  the  pressure  upon  the 
popliteal  artery,  the  pulsations  in  the 
branches  below  are  frequently  interrupted, 
and  in  one  instance  this  pressure  was 
sufiicient  to  produce  finally  a  dry  gangrene. 
Dr.  Gorde  relates  a  case  in  the  Bulletin 
de  TMrapeutique,  occurring  in  a  woman  nearly  sixty  years  old.  This 
woman  was  returning  home  at  night  with  a  heavy  burden,  and  in  a 
state  of  intoxication,  when  she  stepped  into  a  ditch  as  deep  as  up  to 
the  middle  of  her  thighs.  The  body  was  thrown  forwards  by  the  fall, 
while  the  feet  stuck  at  the  bottom  of  the  ditch ;  the  whole  force  of 
the  impulse  being  sustained  by  the  thighs.  The  lower  end  of  the 
femur  was  found  driven  downwards  and  backwards,  and  lodged  under 
the  muscles  of  the  calf  of  the  leg;  the  limb  being  shortened  three 
inches.  Reduction  was  promptly  effected,  and  without  inflicting  any 
pain  of  which  the  patient  complained.  In  six  weeks  the  patient  was 
cured. 

Mr.  Toogood  has  reported  also,  in  the  Provincial  Medical  Journal 
of  June  18th,  1842,  an  example  of  complete  dislocation  in  this  direc- 
tion, in  which  the  appearance  was  so  dreadful,  that  Mr.  Toogood  at 
first  despaired  of  being  able  to  reduce  it ;  but  by  directing  two  men 
to  make  counter-extension  while  he  made  extension,  the  reduction  was 
immediately  efiected.  At  the  end  of  one  month  the  patient  was  able 
to  leave  his  bed ;  and  sixteen  years  after,  Dr.  Toogood  saw  him  walking 


Dislocation  of  the  head  of  the  tibia 
forwards. 


'  Walsliam,  Sir  A.  Cooper  on  Disloc,  2d  Lend,  ed.,  p.  188. 

2  B.  Cooper's  ed.  of  Sir  Astley  Cooper  on  Disloc,  &c.,  pp.  214- 

3  Gorde,  Amer.  Journ.  Med.  Sci.,  vol.  xvi.  p.  225,  May,  1835. 


-215. 


DISLOCATION'S    OF    HEAD    OF    TIBIA    OUTWAEDS.  679 

"  with  very  little  lameness.'"  Parker,  of  Liverpool,  has  reported 
another  example  in  the  London  and  Edinburgh  Monthly  Journal  for 
December,  18i2,  which  was  occasioned  by  the  fall  of  a  heavy  spar  upon 
a  man's  back,  and  the  consequent  violent  bending  of  the  knee  under 
his  body.  In  this  case  the  limb  was  slightly  flexed,  and  the  patella  was 
loose  and  floating.  The  reduction  was  effected  without  much  difficulty 
by  extension  and  counter-extension  made  by  two  men,  while  the 
operator,  placing  his  knee  in  the  ham  of  the  patient,  attempted  to  bring 
the  leg  to  a  right  angle  with  the  thigh.^ 

B.  Cooper  and  Malgaigne  have  each  recorded  several  other  examples 
of  this  accident. 

Dr.  White,  of  this  city,  politely  invited  me  to  see  with  him  a  young 
lad,  get.  10,  whose  tibia  was  partially  dislocated  forwards  eight  weeks 
before,  by  a  boy's  having  hit  the  top  of  his  knee  with  his  head,  while 
they  were  at  play.  His  father,  who  is  himself  a  physician  residing 
near  town,  reduced  the  limb  very  easily,  by  extension  made  with  his 
own  hands,  and  by  pressing  upon  the  projecting  bones.  Violent  in- 
flammation ensued,  but  at  the  time  when  I  saw  him,  the  knee  was 
free  from  soreness  or  swelling,  and  the  motions  of  the  joint  were  nearly 
restored. 


§  3.  Dislocations  of  the  Head  of  the  Tibia  Outwards. 

Occasionally,  owing  to  a  violent  wrench  of  the  knee-joint,  the  lat- 
eral ligaments  upon  one  side  or  the  other  are  ruptured,  and  conse- 
quently the  joint  surfaces  separate  somewhat  from  each,  or  when  the 
limb  is  moved,  the  head  of  the  tibia  may  slide  a  little  forwards  or 
backwards,  or  to  either  side.  These  are  not  properly  examples  of 
subluxation,  nor  should  we  consider  as  belonging  to  this  class  the 
accident  originally  described  by  Mr.  Hey,  as  an  "  internal  derange- 
ment of  the  knee-joint,"  but  which  also  by  some  writers  has  been 
termed  a  "subluxation  of  the  knee."  Of  this  latter  accident,  I  will 
take  occasion  hereafter  to  speak  a  little  more  particularly. 

In  subluxation,  properly  so  called,  if  the  direction  of  the  disloca- 
tion is  outwards,  the  outer  condyle  of  the  femur  rests  upon  the  inner 
articulating  surface  of  the  tibia,  and  if  the  direction  of  the  dislocation 
is  inwards,  the  inner  condyle  of  the  femur  rests  upon  the  outer  articu- 
lating surface  of  the  tibia. 

The  signs  which  characterize  this  accident  are  such  as  cannot  easily 
be  mistaken.  The  limb  is  not  shortened,  nor  is  there  anything  es- 
pecially diagnostic  in  its  position,  since  it  has  been  found  to  be  some- 
times flexed,  and  at  other  times  straight ;  but  the  strong  lateral  pro- 
jections made  by  the  inner  condyle  of  the  femur  on  the  one  hand,  and 
by  the  heads  of  the  tibia  and  fibula  on  the  other,  cannot  fail  to  in- 
form us  as  to  the  true  nature  of  the  accident. 

The  treatment  will  not  differ  essentially  from  that  which  has 
already  been  recommended  in  dislocations  of  the  tibia  backwards  or 

1  Toogood,  Amer.  Journ.  Med.  Sci.,  vol.  xxxi.  p.  465.  ^  E.  Parker,  ibid. 


680 


DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA. 


forwards.     If  any  other  expedients  can  prove  useful,  thej  must  be  left 
to  the  judgment  of  the  surgeon  whenever  the  exigencies  of  the  case 
shall  demand  them. 

I  have  already  mentioned  the  case  of  N.  Smith, 
who,  in  consequence  of  a  fall  from  a  window,  had 
a  dislocation  of  the  right  femur,  tibia,  and  patella. 
The  tibia  was  subluxated  outwards,  and  the  leg 
was  partially  flexed  upon  the  thigh,  with  the  toes 
everted.  By  moderate  extension,  made  with  my 
own  hands,  united  with  alternate  flexion  and  ex- 
tension, the  bone  was  easily  and  promptly  restored 
to  its  place.  Having  reduced  the  femur  also,  the 
limb  was  laid  over  a  gently  inclined  plane  made 
of  pillows;  and  cloths  moistened  with  cool  water 
were  kept  constantly  applied  to  the  knee  for  many 
days.  _  Very  little  swelling  followed  the  accident, 
and  his  recovery  was  rapid  and  complete. 

A  man  was  received  into  the  North  London 
Hospital,  with  a  partial  dislocation  of  the  tibia  out- 
wards, and,  although  the  knee  was  much  swollen, 
the  nature  of  the  injury  was  easily  determined. 
The  knee  was  immovable,  and  the  toes  turned  out- 
wards. Mr.  Hallam,  the  house  surgeon,  reduced  it 
by  extension  and  counter-extension  made  by  his  own  hands.^ 

Mr.  Pitt  records  a  similar  case  in  a  young  lady,  produced  by  a  fall 
down  a  flight  of  stairs.  It  was  reduced  easily  by  extension  and 
counter-extension.  Inflammation  followed,  but  it  was  finally  con- 
trolled, and  she  regained  the  use  of  her  limb.^ 

In  one  case  of  subluxation,  mentioned  by  Sir  Astley  Cooper,  and 
in  a  second  recorded  by  Bransby  Cooper,  the  recovery  of  the  func- 
tions of  the  joint  did  not  seem  to  have  been  so  rapid;  the  joint  re- 
maining unstable  and  tender  for  a  long  time  afterwards.^ 


Subluxation  of  the  tead 
of  the  tibia  outwards. 


§  4.  Dislocations  or  the  Head  op  the  Tibia  Inwards. 

There  is  nothing  peculiar  in  either  the  signs,  condition,  or  treat- 
ment of  this  accident,  as  distinguished  from  a  dislocation  outwards, 
to  demand  of  us  a  special  consideration. 

Sir  Astley  Cooper  has  mentioned  two  cases  of  subluxation  inwards, 
and  Mr.  B.  Cooper  has  added  to  these  a  third.  Sir  Astley  remarks 
that  in  the  first  accident,  the  only  one  indeed  which  he  had  himself 
ever  seen,  he  was  struck  with  three  circumstances:  first,  the  great 
deformity  of  the  knee  from  the  projection  of  the  tibia;  second,  the 
ease  with  which  the  bone  was  reduced  by  direct  extension;  and  third, 
by  the  little  inflammation  which  followed.     The  second  case  of  which 

'  Hallam,  Amer.  Journ.  Med.  Sci.,  vol.  xix.  p.  251. 

^  Pitt,  ibid.,  vol.  xxxi.  p.  465. 

3  B.  Cooper's  ed.  of   Sir  Ast.,  op.  cit.,pp.  211-13. 


HEAD    OF    THE    TIBIA    BACKWAEDS    AND    OUTWARDS.      681 


Fig.  278. 


Sir  Astley  speaks  was  communicated  to  Tiim  by  a  Mr.  Eichards.  In 
this  case  the  fibula  was  also  broken,  and  the  reduction  was  accom- 
plished only  after  extension  had  been  made  by 
several  persons  for  half  an  hour.  The  limb  became 
excessively  swollen,  and  remained  so  for  manv 
weeks.  Eighteen  months  after  the  accident  the 
knee  continued  somewhat  stiff,  and  there  was  an 
unnatural  lateral  motion  in  the  joint,  from  the 
injury  which  the  ligaments  had  sustained.  The 
patient  referred  to  by  Bransby  Cooper  had  met 
with  the  accident  by  a  fall  upon  the  foot  with  his 
leg  bent  under  him ;  and  a  fellow  workman  had 
reduced  the  bones  by  extension  and  pressure.  Mr. 
Cooper  thinks  that  not  only  the  internal  lateral 
ligament  was  torn,  but  also  some  fibres  of  the 
vastus  externus  and  the  crucial  ligaments.  Violent 
inflammation  ensued,  which  did  not  permit  him  to 
leave  the  hospital  until  after  about  two  weeks.^ 
Fergusson  has  seen  two  examples  of  unreduced 
subluxation  inwards,  in  both  of  which  the  patients 
had  regained  useful  limbs.^ 

Malgaigne  mentions  that  Boyer,  Costallat,  and 
Key,  had  each  seen  one  similar  example;  and  he 
also  enumerates  two  additional  cases  of  complete  luxation  attended 
with  a  protrusion  of  the  bone  through  an  external  wound ;  in  both 
of  which  the   reduction  was  easily  effected  and  the  patients  reco- 
vered.^ 


Subluxation  of  the  head 
of  the  tibia  inwards. 


§  5.  Dislocations  of  the  Head  or  the  Tibia  Backwards  and  Outwards. 

In  June,  1853,  Henry  J.,  of  Dansville,  N.  Y.,  set.  24,  was  thrown  by 
an  enraged  bull,  and  his  left  leg  being  caught  under  the  knee  by  the 
horns,  was  twisted  violently.  Dr.  Prior,  of  Dansville,  and  Batton,  of 
Burns,  were  called,  and  found  the  left  knee  completely  dislocated; 
the  tibia  being  displaced  backwards  beyond  the  condyles  of  the  femur, 
and  also  a  little  outwards.  The  foot  and  leg  were  inclined  outwards. 
With  the  assistance  of  four  men,  extension  and  counter-extension  were 
made  in  the  line  of  the  axis  of  the  limb,  and  the  reduction  was  easily 
accomplished.  Pasteboard  splints,  bandages,  &c.,  were  applied  to 
maintain  the  bones  in  place;  but  the  swelling  came  on  rapidly,  and 
in  the  evening  these  dressings  were  removed.  The  limb  was  now  laid 
over  a  double  inclined  plane  carefully  padded,  in  order  to  press  the 
upper  end  of  the  tibia  forwards,  as  it  manifested  a  constant  inclination 
to  become  displaced  backwards.  This  apparatus  was  employed  six 
weeks,  with  the  exception  of  two  or  three  days,  during  which  the 
limb  was  laid  upon  pillows,  but  as  the  pillows  did  not  sufficiently 


'  B.  Cooper,  ed.  of  Sir  Ast.,  op.  cit.,  pp.  211-13. 
^  Malgaigne,  op.  cit.,  torn.  ii.  p.  956. 


2  Fergusson,  op.  cit.,  p.  284. 


682  DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA. 

support  the  back  of  the  tibia,  the  double  inclined  plane  was  resumed. 
After  the  removal  of  the  plane,  during  seven  weeks  longer,  an  angular 
splint  was  kept  closely  applied  to  the  back  of  the  limb. 

Seven  months  after  the  accident,  on  the  23d  of  January,  1854,  Dr. 
Robinson,  of  Hornellsville,  brought  the  gentleman  to  me.  I  found  the 
bones  displaced  backwards  about  three-quarters  of  an  inch,  and  half  an 
inch  outwards,  or  to  the  fibular  side.  This  was  the  position  of  the 
bones  when  he  was  sitting  with  his  leg  bent  at  a  right  angle  with  the 
thigh,  but  when  he  stood  erect  and  bore  some  weight  upon  his  foot, 
the  outward  displacement  ceased,  and  the  backward  displacement  only 
remained.  It  was  very  easy,  however,  in  whatever  position  the  leg 
might  be,  to  push  the  bones  forwards  by  the  hands  until  nearly  all 
deformity  had  disappeared.  He  could  flex  the  leg  to  a  right  angle 
with  the  thigh,  and  straighten  it  completely,  but  he  could  not  lift  the 
foot  and  leg  from  the  floor  while  sitting  with  his  limb  extended  in 
front  of  him.  He  was  unable  to  bear  sufficient  weight  upon  the  foot 
to  use  it  at  all  in  progression,  on  account  of  the  inability  to  fix  and 
steady  the  limb,  but  not  on  account  of  any  pain  or  soreness  which  it 
occasioned. 

It  was  very  plain  that  the  surgeons  were  not  in  fault  for  this  un- 
fortunate condition ;  indeed  they  seem  to  have  exercised  throughout 
great  ingenuity  and  skill  in  its  management, 

I  directed  the  young  man  to  Mr.  John  C.  Seiflfert,  our  very  ingenious 
instrument  maker,  who  has  since  succeeded,  I  learn,  in  adapting  to  his 
knee  a  mechanical  contrivance  which  enables  him  to  walk  quite  well. 

Thomas  Wells,  of  Columbia,  South  Carolina,  has  described  a  similar 
accident,  the  tibia  being  dislocated  outwards  and  backwards,  which 
terminated  fatally  on  the  fourth  day,  in  consequence  mainly  of  ex- 
posure, intemperance,  and  neglect  to  apply  for  surgical  aid.  The 
bones  were  never  reduced,  and  the  autopsy  disclosed  also  a  fracture 
of  the  internal  condyle  of  the  femur.^ 


§  6.  Slipping  of  the  Semilunar  Fibro-Cartilages  . 

Syn. — "  Internal  derangement  of  the  knee-joint;"  Hey.  "Partial  dislocation  of  the 
thigh-bone  from  the  semilunar  cartilages  ;"  Sir  Astley  Cooper.  "Subluxation  of  the 
semilunar  cartilages  ;"  Malgaigne.  "Subluxation  of  the  knee  ;"  Erichsen.  To  these 
we  think  it  proper  to  add,  as  giving  rise  to  the  same  class  of  symptoms,  "  Floating 
cartilages  in  the  knee-joint." 

We  have  already  expressed  our  opinion  that  this  accident  is  in  no 
proper  sense  a  subluxation  of  the  knee  ;  and  we  should  not,  therefore, 
think  it  worth  while  to  make  any  farther  allusion  to  it,  were  it  not  neces- 
sary in  order  to  enable  the  student  of  surgery  to  distinguish  between 
the  phenomena  which  belong  to  it  and  those  which  belong  strictly  to 
subluxations  of  this  joint. 

Symptoms. — The  patient  is  suddenly  thrown  to  the  ground  while 
walking,  as  if  by  an  instantaneous  loss  of  power  in  the  affected  limb, 

1  Wells,  Amer.  Journ.  Med.  Sci.  vol.  x.  p.  25,  May,  1832. 


SLIPPING    OF    THE    SEMILUNAE    FIBEO-CAETILAGES.        683 

this  loss  of  control  over  the  limb  being  accompanied  usually  with 
sharp  pain,  referred  to  the  region  of  the  knee-joint ;  or  he  trips  his 
toe  against  something  in  his  path,  and  the  toes  becoming  everted,  the 
leg  suddenly  gives  way  under  him ;  in  some  cases  it  has  happened 
when  the  patient  was  turning  in  bed,  the  weight  of  the  bedclothes 
hanging  upon  the  toes  so  as  to  occasion  a  strain  and  rotation  outwards 
at  the  knee-joint,  or  it  follows  upon  a  subluxation  of  the  joint,  as  in 
one  example  which  I  shall  presently  relate. 

If  the  patient  is  walking  when  the  accident  takes  place,  and  he  falls 
to  the  ground,  he  finds  himself  unable  to  move  the  limb,  or  to  stand 
upon  it ;  but  by  manipulation,  the  difficulty  is  as  easily  overcome  as 
it  occurred,  when  immediately  the  motions  of  the  joint  become  free, 
and  he  walks  off  as  if  nothing  had  happened. 

When  the  accident  has  once  taken  place,  it  is  afterwards  exceed- 
ingly liable  to  occur  from  very  slight  causes,  and  eventually  the  knee- 
joint  becomes  tender  and  the  capsule  fills  with  synovia,  indicating  the 
existence  of  subacute  synovitis. 

A  single  example  will  illustrate  the  usual  history  of  these  cases. 

A  young  man,  from  Colesville,  N.  Y.,  set.  28,  consulted  me  on  the  27th 
of  Oct.  1858,  in  relation  to  the  condition  of  his  knee-joint.  He  stated 
that,  on  the  13th  of  Aug.  1858,  while  standing  with  the  whole  weight 
of  his  body  resting  upon  the  left  leg,  a  mate  struck  him  on  the  inside 
of  the  lower  end  of  the  left  femur.  The  blow  was  made  with  the 
palm  of  the  hand,  but  with  sufficient  force  to  throw  him  down.  It, 
was  immediately  noticed  that  the  tibia  was  partially  dislocated  inwards 
at  the  knee-joint.  The  whole  lower  part  of  the  limb  was  inclined 
outwards.  A  person  present  in  the  room  seized  upon  the  foot  and 
by  extension  easily  brought  it  back  to  place ;  the  bone  resuming  its 
position  with  an  audible  snap.  After  this  he  continued  to  walk  about 
until  night.  Two  days  after,  the  knee  had  become  so  much  inflamed 
that  he  was  obliged  to  take  to  his  bed,  on  which  he  was  confined  three 
weeks.  Gradually  the  swelling  subsided,  and  in  about  five  weeks 
after  the  accident  he  began  to  walk  on  crutches.  On  the  23d  of  Sept., 
he  was  walking  in  the  store  without  crutches,  when  he  suddenly  felt 
a  sensation  of  slipping  in  the  joint,  and  he  fell  to  the  floor  as  if  he 
had  been  tripped  up.  At  the  time  when  he  called  upon  me,  this  had 
happened  many  times,  but  it  has  never  been  attended  with  pain.  The 
joint  was  filled  with  synovia,  and  tender,  yet  I  could  distinctly  feel  a 
hard  body  just  to  the  inside  of  the  ligamentum  patellae,  and  which 
moved  freely  under  the  finger. 

Paihological  Anatomy. — The  same  class  of  symptoms,  with  only 
very  slight  modifications,  belongs  probably  to  several  varieties  of  "in- 
ternal derangement  of  the  knee-joint;"  and  first,  it  will  be  remembered 
that  the  semilunar  cartilages  upon  which  the  margins  of  the  condyles 
of  the  femur  rest,  are  attached  to  the  tibia  by  several  ligaments;  but 
when,  from  relaxation  or  a  violent  strain,  any  one  of  these  ligaments 
becomes  elongated  or  gives  way,  the  portion  of  cartilage  which  it 
restrains  is  permitted  to  become  partially  displaced,  and  by  interposing 
its  thick  margin  between  the  deeper  articulating  surfaces  the  bones  are 
separated  and  the  muscles  lose  their  control  over  the  joint;  second, 


684  DISLOCATIONS    OF    THE    HEAD    OF    THE    TIBIA.  ; 

f 

these  ligaments  may  not  only  yield,  but  a  fragment  of  one  of  thi^ 
cartilages  may  become  actually  broken  off  from  the  main  portion': 
third,  the  femur  may  perhaps  escape  behind  some  portion  of  an  in 
terarticular  cartilage  and  thus,  instead  of  the  cartilage  placing  itsel 
between_  the  joint  surfaces,  the  femur  itself  may  have  thrust  it  intd 
this  position;  fourth,  a  cartilage  or  some  portion  of  a  cartilage  mai 
become  hypertrophied,  and  thus  give  rise  to  the  symptoms  described i 
fifth,  in  other  cases  still,  a  bony,  cartilaginous,  fibrinous,  or  calcareou; 
growth  or  concretion  forming  within  the  joint,  and  if  originally 
attached,  becoming  separated  from  the  capsule,  may  move  about  mor"( 
or  less  freely,  and  give  rise  to  the  same  class  of  symptoms  which  w(i 
have  described. 

This  last  variety  has  generally  been  described  under  the  name  o 
"floating  cartilages;"  but  since  these  bodies  are  not  always  cartilagi 
nous,  and  especially  since  they  do  not  always  by  any  means  mov( 
so  freely  as  to  be  properly  designated  as  "floating,"  the  term  is  less 
appropriate  than  that  originally  given  by  Hey,  and  which  we  have" 
chosen  to  adopt. 

Treatment. — For  the  purpose  of  obtaining  immediate  relief  it  is  genel 
rally  sufficient  to  flex  the  leg  completely  and  then  suddenly  extend! 
it,  or  to  combine  this  motion  with  a  slight  twisting  or  rocking  of  the 
knee-joint.  Sometimes  this  experiment  has  to  be  repeated  several 
times  before  it  is  completely  successful,  and  in  a  few  instances  it  has 
failed  altogether.  I  think  I  must  have  met  with  ten  or  twelve  ex-T 
amples  in  the  course  of  my  practice,  and  in  no  instance  has  the  suddei 
flexion  and  extension  of  the  limb  failed  to  overcome  the  difficulty. 

As  to  the  question  of  subsequent  treatment,  especially  as  to  w^hether' 
it  is  proper  to  attempt  their  extirpation  when  they  are  found  to  be 
loose,  or  to  make  any  other  surgical  interference,  I  prefer  to  leave 
its  consideration  to  those  general  treatises  upon  surgery  where  it  more 
properly  belongs. 


CHAPTER    XIX. 

DISLOCATIONS    OF    THE    LOWER   END    OF   THE   TIBIA. 

aS>w.— "Tibio-tarsal  luxations;"  Malgaigne.     "Dislocations   of  the  ankle-joint;" 
Ch.eliTis  and  others.  i„ 

The  tibia  may  be  dislocated  at  its  lower  end  in  four  directions ; 
namely,  inwards,  outwards,  forwards,  and  backwards.  Most  of  these  | 
dislocations  complicate  themselves  with  fractures  of  the  fibula,  or  of  | 
the  tibia,  or  with  fractures  of  both  bones. 

Dupuytren,  Malgaigne,  and  a  few  other  surgeons  have  reported  ex- 
amples also  of  dislocations  forwards  and  inwards. 


I 


DISLOCATIONS    OF    LOWEE    END    OF    TIBIA    INWAEDS.      685 


Boyer,  with  a  majority  of  the  French  writers,  and  several  English 
and  German  surgeons,  speak  of  these  dislocations  as  belonging  to  the 
foot;  consequently  the  outward  dislocation  of  Boyer  is  the  inward 
dislocation  of  Sir  Astley  Cooper,  Malgaigne,  myself  and  others,  who 
prefer  to  regard  the  tibia  as  the  bone  dislocated. 


I 


§  1.  Dislocations  of  the  Lower  End  op  the  Tibia  Inwards. 


Syn. — "Inward  tibio-tarsal  luxations;"  Malgaigne.  "Dislocations  of  the  foot  out- 
wards ;"  Boyer  and  others. 

Causes. — This  dislocation  is  occasioned  generally  by  a  fall  from  a 
height,  upon  the  bottom  of  the  foot,  the  foot  receiving  at  the  same 
moment  a  sufficient  inclination  outwards  to  determine  the  main  force 
of  the  impulse  toward  the  inner  side  of  the  ankle.  It  may  be  pro- 
duced also  by  a  blow  received  directly  upon  the  outside  of  the  leg 
just  above  the  ankle,  or  by  a  violent  twist  or  wrench  of  the  foot  out- 
wards. 

Pathological  Anatomy. — I  have  already,  in  the  chapter  on  fractures 
of  the  fibula,  stated  my  opinion  that  a  large  majority  of  those  acci- 
dents which  have  been  called  inward  and  outward  dislocations  of  the 
tibia,  were  merely  examples  of  lateral  rotation  of  the  astragalus  within 
the  half  ginglimoid  and  half  orbicular  socket  formed  by  the  lower  ex- 
tremities of  the  tibia  and  fibula ;  and  that  true  dislocations,  either 
partial  or  complete,  are  at  this  joint  and  in  these  directions  very  rare 
occurrences.  We  shall  continue,  however,  in  accordance  with  the 
general  practice  of  writers,  to  call  them  all  dislocations,  whether  the 
astragalus  simply  rotates  on  its  axis,  or  is  displaced  laterally  and  hori- 
zontally from  the  tibia. 

In  the  most  common  form  of  the  accident,  then,  when  the  foot  is 
violently  twisted  outwards,  the 

astragalus  becomes  tilted  upon  ^jg-  279. 

its  outer  and  upper  margin  in 
such  a  way  as  that  this  mar- 
gin slides  inwards  and  places 
itself  underneath  the  middle 
portion  of  the  lower  articu- 
lating surface  of  the  tibia;  its 
upper  and  inner  margin  de- 
scends toward  the  extremity 
of  the  malleolus  internus,  and 
the  outer  face  of  the  astragalus 
presents  obliquely  upwards 
and  outwards,  instead  of  di- 
rectly outwards  as  it  would  do         Dislocation  of  the  lower  end  of  the  tibia  inwards. 

in  its  natural  position.      This 

cannot  occur  without  a  rupture  of  the  internal  tibio-tarsal  ligaments, 
or  a  fracture  of  the  malleolus  internus,  or  both ;  indeed,  a  fracture  of 
the  internal  malleolus  is  a  very  common  circumstance  in  connection 


686 


DISLOCATIONS    OP    THE    LOWEE    END    OF    THE    TIBIA. 


With  this  form  of  dislocation.  Much  more  frequently,  however,  the 
fibula  Itself  gives  way  at  a  point  within  from  two  to  five  inches  of  its 
lower  extremity;  or  sometimes  the  fracture  in  the  fibula  occurs 
through  that  portion  which  forms  the  malleolus  externus.  For  more 
particular  information  as  to  the  causes  and  relative  frequency  of  these 
fractures,  I  refer  the  reader  to  the  chapter  on  fractures  of  the  fibula 

Karely  it  happens  that  instead  of  this  lateral  rotation  of  the  astra- 
galus, there  occurs  a  true  lateral  displacement  of  the  tibia  inwards 
upon  the  astragalus,  and  the  outer  portion  of  the  lower  articulating 
surface  of  the  tibia  comes  to  rest  upon  the  inner  portion  of  the  upper 
articulating  surface  of  the  astragalus ;  or  it  may  slide  completely  off 
in  the_  same  direction ;  a  result  which  is  usually  attended  with  a 
laceration  of  the  muscles  and  integuments,  converting  the  accident 
into  a  compound  dislocation.  In  some  cases  this  extreme  displace- 
ment occurs  without  such  lacerations. 

In  this  form  of  the  accident,  the  true  lateral  luxation,  the  fibula  may 
remain  unbroken  and  undisturbed,  the  tibia  merely  having  become 
displaced  inwards;  or  the  fibula  may  give  way  also  above  the  articula- 
tion, while  the  malleolus  internus,  and  the  internal  lateral  ligaments 
are  equally  liable  to  rupture  as  in  the  other  form  of  the  accident. 

Sometimes  in  addition  to  these  complications,  the  lower  end  of  the 
tibia  IS  found  to  be  broken  obliquely  upwards  and  outwards  from  the 
articulating  surface,  leaving  that  fragment  attached  to  the  fibula  which 
cori^esponds  to  the  inferior  peroneo-tibial  articulation. 

Spmjjioms.— The  foot  is  more  or  less  violently  abducted,  the  sole  of 

Fig,  280. 


Dislocation  of  the  lower  end  of  the  tibia  inwards. 


dislocatiojs^s  of  lower  end  of  tibia  inwaeds.    687 

the  foot  presenting  downwards  and  outwards  instead  of  directly  down- 
wards;  the  malleolus  internus  projects  strongly  at  the  inner  side  of 
the  joint;  and  at  the  outer  side  there  is  a  corresponding  depression, 
generally  most  marked  a  little  above  the  articulation  near  the  point 
of  fracture  in  the  fibula.  The  pain  is  very  great,  and  the  foot  is 
immovably  fixed,  so  far  as  the  volition  of  the  patient  can  determine 
motion,  but  the  surgeon  can  generally  move  it  pretty  freely,  yet  not 
without  causing  a  great  increase  of  the  pain.  When  the  dislocation 
is  complete,  and  the  fibula  also  is  broken,  the  limb  becomes  slightly 
shortened. 

Treatment. — When  the  accident  is  of  the  nature  of  a  simple  rotation 
of  the  astragalus  upon  its  axis,  the  reduction  is  often  accomplished 
with  the  greatest  ease  by  seizing  upon  the  foot,  and  forcibly  adductino- 
it.  ISTot  unfrequently  the  patient  himself,  or  some  other  person  who 
is  present,  has  effected  the  reduction  before  the  surgeon  is  called.  In 
other  cases,  and  especially  when  it  partakes  of  the  nature  of  a  true 
dislocation,  much  difficulty  is  sometimes  experienced  in  the  reduction. 
The  surgeon  ought  then  to  flex  the  leg  upon  the  thigh,  in  order  to 
relax  the  gastrocnemii  muscles,  and  holding  the  foot  midway  be- 
tween flexion  and  extension,  he  should  pull  steadily  upon  it  with  his 
own  hands,  while  an  assistant  makes  counter-extension,  and  supports 
the  limb  with  his  hands,  grasping  the  thigh  above  the  knee.  At  the 
same  moment  lateral  pressure  should  be  made  upon  the  projecting 
bone  in  the  direction  of  the  articulation.  It  is  of  some  use,  also  to 
occasionally  flex  and  extend  the  limb  moderately,  and  to  give  to  the 
foot  a  gentle  rocking  motion.  If  more  force  is  needed,  it  mav  be  ap- 
plied by  placing  the  limb  over  a  firm  double  inclined  fracture  splint, 
and  making  the  extension  by  the  aid  of  a  screw  attached  to  the  foot- 
board, as  we  have  suggested  in  certain  cases  of  dislocation  at  the  knee. 
Or  we  may  employ  the  pulleys  after  the  manner  represented  in  the 
accompanying  drawing. 

FiR.  281. 


Charles  Sauer,  of  this  city,  aged  about  thirty  years,  while  carrying 
a  weight  upon  his  shoulders,  on  the  6th  of  May,  1854,  slipped  upon 
the  side  walk  and  fell,  dislocating  the  left  tibia  inwards  and  fracturmg 


DISLOCATIONS    OF    THE    LOWEE    END    OF    THE    TIBIA. 

the  fibula  four  inches  from  its  lower  end.  I  was  in  attendance  soon 
after  the  accident  occurred,  and  found  the  tibia  projecting  inwards 
with  the  other  symptoms  usually  accompanying  a  simple  rotation  of 
the  astragalus  upon  its  axis.  Seizing  the  foot  with  my  hands,  and 
flexmg  the  leg,  while  an  assistant  held  up  the  thigh  and  made  counter- 
extension,  I  had  scarcely  begun  to  pull  upon  the  foot  before  the  re- 
duction was  eflPected.  Dupuytren's  splint  was  at  once  applied,  and 
the_  subsequent  mfiammation  was  so  trivial  as  scarcely  to  deserve 
notice.     In  six  weeks  the  limb  was  sound,  and  free  from  all  anchylosis 

In  my  report  on  dislocations,  made  to  the  New  York  State  Medical 
Society  for  the  year  1855,  I  have  mentioned  twelve  similar  examples 
m  addition  to  some  examples  of  compound  dislocations,  all  of  which 
were  easily  reduced,  but  the  results  were  not  always  so  favorable 

If,  as  rarely  happens,  the  tibia  is  broken  obliquely  into  the  ioint 
the  complete  reduction  of  the  dislocated  tibia  may  be  found  impos- 
sible owing  to  the  obstacle  presented  by  the  displaced  fra^rment 

The  following  I  am  disposed  to  regard  as  examples  of°dislocation 
accompanied  with  fracture  of  the  tibia  within  the  articulation 

Brockway,  of  Cortland,  N.  Y.,  aged  about  twenty-seven  years,  con- 
suited  me  at  my  office  a  few  years  since  in  relation  to  the  condition  of 
his  foot.  _  I  found  the  tibia  dislocated  inwards  and  projectino-  more 
than  an  inch  beyond  the  astragalus;  the  foot  was  turned  outwards 
compelling  him  to  walk  upon  the  inside  of  his  foot;  the  fibula  was 
bent  inwards  against  the  tibia,  at  a  point  about  four  inches  above  the 
ankle,  which  seemed  to  have  been  the  seat  of  fracture  of  this  bone 
lie  stated  to  me  that  immediately  after  the  receipt  of  the  iniury 
which  was  occasioned  by  a  fall  from  a  height  upon  the  bottom  of  his 
foot,  he  had  consulted  a  surgeon.  Dr.  A.  B.  Shipman,  of  Cortland, 
and  that  although  Dr.  Shipman  made  repeated  and  violent  efforts  to 
effect  the  reduction,  he  had  been  unable  to  do  so.  Indeed  the  bone 
had  never  been  removed  from  the  position  in  which  it  was  at  first 
placed. 

J.  Borland,  of  Erie  Co.,  K  Y.,  ast.  31,  fell  under  a  rolling  log  and 
dislocated  his  left  tibia  inwards,  breaking  off  the  internal  malleolus, 
and  fracturing  the  fibula  four  inches  from  its  lower  end.  Dr.  Sweet- 
Jand,  an  old  and  experienced  practitioner,  was  immediately  called  who 
with  another  surgeon,  failed,  after  repeated  efforts,  to  reduce  the  dis- 
location I  saw  the  patient,  in  consultation  with  these  gentlemen 
twenty-four  hours  after  the  accident.  The  foot  and  ankle  were  some- 
what swollen  and  discolored.  The  lower  end  of  the  tibia  projected 
so  far  inwards  as  to  threaten  a  rupture  of  the  skin ;  the  foot  was 
strongly  everted.  We  first  flexed  the  leg  upon  the  thigh,  and  made 
extension  with  our  hands,  in  the  manner  I  have  already  directed  This 
we  continued  several  minutes;  finally  moving  the  limb  in  various 
directions  and  adding  forcible  pressure  upon  the  inside  of  the  pro- 
jecting tibia.  _  We  then  placed  the  leg  over  a  double-inclined  plane 
and,  securing  it  firmly  in  place,  we  attached  a  screw  to  the  foot  through 
a  sandal  and  gaiter,  and  while  the  leg  was  well  flexed  upon  the  thi |h 
we  renewed  the  extension  and  lateral  pressure.  This  was  continued 
with  the  application   of  more  or  less  power,  during  half  an  hour 


DISLOCATIONS    OF    LOWER    END    OF    TIBIA    OUTWARDS,      689 

meanwhile  changing  the  position  of  the  limb  occasionally  by  varying 
the  angle  of  the  splint.  Our  efforts  were  prolonged  in  all  more  than 
one  hour,  when,  as  we  had  made  no  impression  upon  the  bone,  and 
the  patient  had  repeatedly  implored  us  to  desist,  the  attempt  was 
given  over.  The  end  of  the  tibia  seemed  to  rest  partly  upon  the 
astragalus,  and  the  extension  was  plainly  all  that  was  demanded,  but 
the  obstacle  was  beyond  doubt  within  the  articulation,  or  rather  be- 
tween the  tibia  and  fibula. 

Four  weeks  after  the  accident,  Mr.  Borland  walked  on  crutches, 
and  during  a  year  he  was  compelled  to  use  a  cane,  but  since  that  time, 
a  period  of  twelve  years,  he  has  walked  without  any  artificial  support. 
For  a  year  or  two  he  felt  a  yielding  in  his  ankle,  as  the  weight  of  his 
body  settled  upon  his  limb;  but  this  gradually  ceased,  and  for  some 
years  past  he  has  walked  without  any  halt,  and  seems  to  step  as  firmly 
as  before  the  accident.  The  foot  still  inclines  outwards;  the  tibia 
projects  inwards  one  inch,  and  the  broken  ends  of  the  fibula  can  be 
felt  resting  against  the  tibia,  where  they  are  united. 

Not  long  since  I  had  occasion  to  amputate  a  limb  for  a  compound 
dislocation  inwards  at  the  ankle-joint,  and  the  possibility  of  this  frac- 
ture was  confirmed  by  the  dissection.  About  one-third  of  the  outer 
portion  of  the  articular  surface  was  broken  off  obliquely,  and  the 
fragment  was  lying  so  displaced  that  a  reduction  would  have  been 
rendered  impossible. 

Dr.  Townsend,  of  Boston,  has  reported  a  case  of  compound  dislo- 
cation, in  which  also  amputation  became  necessary  ;  and,  with  other 
injuries,  the  dissection  showed  a  fragment  from  the  outer  margin  of 
the  tibia,  one  inch  and  a  half  long,  and  one  inch  thick  at  its  widest 
part,  with  a  very  sharp  point,  displaced  and  lying  almost  transversely 
over  the  astragalus.^ 

For  a  more  full  account  of  the  prognosis  and  the  general  manage- 
ment of  these  cases  subsequent  to  the  reduction,  I  beg  again  to  refer 
the  reader  to  the  chapter  on  fractures  of  the  fibula ;  and  for  my  views 
in  relation  to  the  treatment  of  compound  dislocations  of  the  ankle-joint 
I  will  refer  also  to  the  chapter  on  compound  dislocations  of  the  long 
bones. 

§  2.  Dislocations  of  the  Lower  End  of  the  Tibia  Outwards. 

Syn. — "Outward  tibio-tarsal  luxations;"  Malgaigne.  "Dislocations  of  the  foot  in- 
wards," of  others. 

The  causes  are  the  same  or  similar  to  those  which  are  known  gene- 
rally to  produce  dislocations  inwards;  only  that  the  force  of  the  concus- 
sion or  the  direction  of  the  rotation  must  have  been  reversed. 

The  external  lateral  ligaments,  peroneo-tarsal,  are  either  ruptured 
or  the  lower  portion  of  the  fibula  gives  way,  or  both  of  these  circum- 
stances may  have  happened;  while  the  internal  malleolus  may  also 
yield  to  the  shock  and  to  the  weight  of  the  body  now  resting  upon  it. 

1  Townsend,  Mass.  Hosp.  Reports,  Bost.  Med.  and  Surg.  .Journ.,  vol.  xxxiii.  p.  277. 
4i 


690      DISLOCATIONS    OF    THE    LOWER    END    OF    THE    TIBIA, 


The  nature  of  the  accident  may  vary  also  in  respect  to  the  relative 
position  of  the  articular  surfaces;  the  astragalus  may  simply  rotate  on 
its  inner  and  upper  margin,  or  the  tibia,  with  the  fibula  of  course,  may 
actually  slide  outwards  until  the  lower  end  of  the  tibia  more  or  less 
completely  abandons  the  upper  surface  of  the  astragalus. 

The  modes  of  reduction  and  the  general  principles  of  treatment 
subsequently,  will  not  differ  from  those  which  we  have  mentioned  as 

suitable  for  dislocations  in  the 
Fig.  282.  opposite  direction.     The  exam- 

ples which  have  fallen  under  my 
observation  are  not  numerous, 
but  the-  reduction  has  always 
been  easily  effected.  Thus  a 
man,  ast.  21,  fell  from  a  scaffold- 
ing, alighting  upon  his  feet.  He 
says  that  his  left  foot  struck  the 
ground  obliquely  and  upon  its 
outer  margin.  I  found  the  fib- 
ula projecting  very  strongly  out- 
wards, evidently  carrying  with 
it  the  tibia;  the  malleolus  in- 
ternus  was  broken  oft",  and  the 
foot  forcibly  turned  inwards. 
Without  either  flexing  the  leg 
upon  the  thigh  or  calling  to  my 
aid  any  degree  of  counter-exten- 
sion except  what  was  made  by 
the  weight  of  the  body,  I  grasped 
the  foot  and  drew  upon  it  gently 
while  at  the  same  moment  I  ro- 
tated the  foot  outwards.  Imme- 
diately the  bones  resumed  their 
places. 

In  June  of  1846,  Henry  Wil- 
son, get.  38,  consulted  me  in  rela- 
tion to  his  foot,  which  he  said 
had  been  dislocated  four  weeks 
before.  He  had  fallen  upon  the 
outside  of  his  foot  and  turned  it  suddenly  inwards,  so  that  when  he 
looked  at  it  he  found  the  sole  presenting  toward  the  opposite  side. 
Seizing  upon  it  with  both  hands,  he  pressed  it  forcibly  outwards,  and 
the  reduction  immediately  took  place  with  a  snap.  Very  little  soreness 
followed,  nor  was  he  confined  to  his  house  a  single  day.  He  had  con- 
tinued to  walk  about  with  only  a  slight  halt  in  his  gait,  nor  would  he 
have  thought  it  necessary  to  consult  me  at  all  except  that  the  tender- 
ness had  not  yet  disappeared.  He  was  not  aware  that  the  fibula  had 
been  broken  also  until  I  called  his  attention  to  the  fact.  The  fracture 
had  taken  place  two  inches  above  the  ankle;  and,  although  it  was 
already  united,  the  depression  occasioned  by  its  having  fallen  in  some- 
what toward  the  tibia  was  very  plainly  felt  and  recognized. 


Dislocation  of  tlie  lower  end  of  the  tibia  outwards. 


LOWER    END    OF    THE    TIBIA    FORWARDS. 


691 


3.  Dislocations  of  the  Lower  End  of  the  Tibia  Forwards, 


Syn. — "Forward  tibio-tarsal  luxations;"  Malgaigne. 
wards,"  of  others. 


•  Dislocations  of  the  foot  back- 


Causes. — This  dislocation  may  be  produced  by  a  violent  extension 
of  the  foot  upon  the  leg;  as,  for  example,  when,  the  foot  being  en- 
gaged under  a  piece  of  timber,  the  body  falls  backwards  to  the  ground; 
or  when,  the  leg  remaining  fixed,  a  heavy  weight  descends  upon  the 
front  of  the  foot ;  or  it  may  be  caused  by  a  fall  upon  the  bottom  of 
the  foot,  the  foot  resting  upon  an  inclined  plane ;  by  a  blow  upon  the 
back  of  the  tibia,  or  possibly,  even  by  the  toes  being  brought  violently 
in  contact  with  some  firm  body. 

Pathological  Anatomy. — The  displacement  may  be  very  slight,  so 
that  the  end  of  the  tibia  is  only  a  little  advanced  upon  the  astragalus ; 
or  it  may  be  such  that  the  tibia  rests  one-half  upon  the  naviculare  and 
one- half  upon  the  astragalus,  or  it  may  even  desert  the  astragalus  en- 
tirely. In  these  latter  examples,  the  lateral  ligaments  suffer  more  or 
less  complete  laceration.  The  fibula  is  generally  broken  on  a  level 
with  the  articulation,  the  malleolus  internus  also  in  some  cases,  and 
still  more  rarely  a  fracture  occurs  through  the  posterior  margin  of  the 
articular  surface  of  the  tibia. 


Fig.  283. 


Fig.  284. 


Dislocations  of  the  lower  end  of  the  tibia  forwards. 

Symptoms. — The  length  of  the  foot  in  front  of  the  tibia  is  dimi- 
nished, while  the  projection  of  the  heel  is  correspondingly  increased ; 
the  toes  are  turned  downwards,  and  the  heel  drawn  upwards,  and  fixed 
in  this  position  ;  the  end  of  the  tibia  may  generally  be  distinctly  felt 
in  front  of  the  astragalus;  the  extensor  tendons  of  the  toes  are 
sharply  defined,  while  the  tendo-Achillis  is  curved  forwards,  and  tense. 

Treatment.— The  reduction  is  to  be  attempted  by  flexing  the  leg 
upon  the  thigh,  and  making  extension  from  the  foot,  while,  at  the 
same  moment,  pressure  is  made  upon  the  front  of  the  tibia  and  against 


692      DISLOCATIONS    OF    THE    LOWEE    END    OF    THE    TIBIA. 

the  heel.  When  the  bone  begins  to  slide  into  place,  the  foot  should 
be  forcibly  flexed  upon  the  leg.  A  slight  lateral  motion  or  rotation 
in  either  direction  may  assist  in  restoring  the  bones  to  place. 

In  general,  the  dislocation  has  been  easily  reduced,  but  in  a  ma- 
jority of  the  examples  recorded  great  difficulty  has  been  experienced 
in  maintaining  the  reduction  ;  and  in  a  few  cases  it  has  been  found 
impossible  to  do  so. 

In  order  to  maintain  the  reduction,  the  leg,  flexed  upon  the  thigh, 
should  be  laid  on  its  back  in  a  box;  and  the  foot  supported  firmly 
against  a  foot-piece  placed  at  a  right  angle  with  the  box.  In  this 
position,  the  weight  of  the  leg  will  tend  somewhat  to  overcome  the 
action  of  the  muscles  which  are  disposed  to  displace  the  foot  backwards. 
Generally  it  will  be  found  necessary  to  make  additional  pressure  di- 
rectly upon  the  front  of  the  leg  above  the  ankle ;  which,  in  order  that 
it  may  not  prove  mischievous,  must  be  efl:ected  with  some  soft  material, 
and  must  be  applied  over  a  broad  surface.  Perhaps  nothing  will 
better  answer  these  indications  than  to  pass  a  cotton  band,  six  or 
eight  inches  in  width,  through  slits  or  mortices  in  the  sides  of  the  box ; 
these  slits  being  of  a  width  equal  to  the  width  of  the  band,  and  placed  at 
a  point  sufficiently  below  the  level  of  the  spine  of  the  tibia,  so  that  when 
the  band  is  made  fast  underneath  the  box  it  shall  press  the  leg  firmly 
backwards.  To  prevent  the  heel  from  suffering  in  consequence  of  this 
pressure,  it  also  should  be  supported,  or  suspended  by  another  band 
passing  underneath  the  heel  and  fastened  above  to  the  top  of  the  foot- 
board. 

Dupuytren  relates  the  following  example  of  this  rare  accident: — 

Pierre  Froment,  aet.  33,  was  carrying  a  heavy  weight  upon  his  back, 
and  had  his  right  foot  in  advance,  when  by  accident  he  came  suddenly 
in  contact  with  a  beam  placed  across  his  path.  Under  the  fear  of 
being  precipitated  forwards,  he  made  a  sudden  efibrt  to  throw  his  body 
backwards,  by  which  he  lost  his  balance,  and  fell  with  the  point  of  the 
left  foot  inclined  inwards  and  forwards,  and  his  whole  weight  was 
thrown  first  on  the  outer  side,  and  then  on  the  front  of  the  ankle- 
joint. 

On  examination  the  leg  seemed  to  be  planted  upon  the  middle  of  the 
foot;  the  toes  were  directed  downwards  and  the  heel  drawn  up.  On  the 
instep  there  was  a  large  bony  prominence,  over  which  the  extensor 
tendons  of  the  toes  were  stretched  like  tense  cords.  Behind  the  joint 
was  a  deep  hollow,  at  the  bottom  of  which  the  tendo-Achillis  could 
be  felt,  forming  a  tense,  resisting,  semicircular  cord,  with  its  concavity 
directed  backwards.  The  fibula  was  also  broken;  the  lower  end  of 
the  lower  fragment  remaining  attached  to  the  foot,  while  the  upper 
end  of  the  same  fragment  was  carried  forwards  by  the  displacement  of 
the  tibia,  so  that  it  lay  nearly  horizontally,  with  its  broken  extremity 
directed  forwards. 

Dupuytren  directed  one  assistant  to  fix  the  leg,  and  a  second  to 
make  extension  from  the  foot,  while  Dupuytren  himself,  standing  on 
the  outer  side  of  the  limb,  forced  the  heel  forwards  and  the  tibia  back- 
wards. The  first  attempt  succeeded  partially,  and  the  second  com- 
pleted the  reduction.     The  limb  was  then  placed  in  the  apparatus 


LOTTER    END    OF    THE    TIBIA    BACEWAEDS.  693 

employed  by  this  surgeon  for  a  fractured  fibula,  which  we  have 
before  described,  and  laid  on  its  outer  side  in  a  semiflexed  position. 
The  patient  recovered  rapidly,  and  in  little  more  than  a  month  he  was 
able  to  walk.^ 

But  such  fortunate  results  have  not  usually  been  observed ;  indeed 
Dupuytreu  encountered  much  more  serious  difficulties  in  two  other 
cases  which  came  under  his  own  notice,  one  of  which  he  has  himself 
recorded.  This  was  in  the  person  of  a  woman  set.  48,  who  was  brought 
to  the  Hotel  Dieu  in  1815,  the  accident  having  just  happened  from  a 
slip  in  going  down  stairs.  The  fibula  was  broken,  and  also  a  frag- 
ment was  broken  from  the  tibia.  The  house  surgeon  reduced  the 
bones  and  placed  the  limb  in  the  ordinary  apparatus  for  broken 
legs,  but  on  the  following  day  Dupuytren  found  them  reluxated,  and 
laid  the  limb  on  his  own  splint,  but  the  pressure  requisite  to  keep 
the  tibia  in  place  soon  induced  sloughing,  ulceration,  and  abscesses, 
and  after  four  months'  treatment,  during  which  time  the  tibia  had  been 
repeatedly  displaced,  she  left  the  hospital  able  to  use  her  limb,  but 
with  a  certain  amount  of  incurable  deformity.^ 

Malgaigne  mentions  the  third  example  as  having  been  seen  by 
himself  in  Dupuytren's  service  in  1832,  in  which  case  the  attempt  to 
maintain  the  reduction  by  a  tourniquet  resulted  in  gangrene  and 
finally  the  death  of  the  patient.^  Earle  lost  a  patient  after  amputation 
made  on  the  eighth  day.  The  tibia  could  not  be  kept  in  place,  and  the 
amputation  became  necessary  on  account  of  the  final  protrusion  of 
the  bone  through  the  integuments,  which  had  sloughed." 


§  4.  Dislocations  of  the  Lower  End  of  the  Tibia  Backwards. 

Syn. — "BackTvard  tibio-tarsal  luxations;"  Malgaigne.  "Dislocations  of  the  foot 
forwards,"  of  others. 

^loTQ  rare  even  than  the  dislocations  forwards,  Malgaigne  has  never- 
theless succeeded  in  collecting  five  examples. 

They  appear  to  have  been  produced  generally  by  a  cause  the  reverse 
of  that  which  we  have  seen  to  produce  so  often  the  preceding  disloca- 
tion. Thus  while  the  dislocation  forwards  is  produced  most  frequently 
when  the  foot  is  in  violent  extension,  this  dislocation  has  occurred 
in  at  least  two  or  three  cases,  when  the  foot  was  forcibly  flexed  upon 
the  leg. 

The  symptoms  are  strongly  marked  and  characteristic.  The  length 
of  the  foot  from  the  tibia  to  the  ends  of  the  toes  is  increased  one  inch 
or  more ;  the  heel  being  correspondingly  shortened,  or  rather  wholly 
obliterated;  a  portion  of  the  articulating  surface  of  the  astragalus  may 
be  distinctly  felt  in  front  of  the  tibia  ;  the  posterior  surface  of  the  tibia 
touches  the  tendo-Achillis ;  the  leg  is  shortened  and  the  malleoli  ap- 
proach the  sole  of  the  foot. 

In  most  cases  one  or  both  of  the  malleoli  have  been  broken ;  and 

'  Dupuytren,  Injuries  and  Dis.  of  Bones.     London  ed.,  p.  278. 

^  Op.  cit.,  p.  276.  '■"  Malgaigne,  op.  cit.,  p.  1044.  "  Ibid.,  p.  1044. 


694      DISLOCATIONS    OP    THE    UPPER    END    OF    THE    FIBULA. 

R.  W.  Smith,  who  has  reported  one  of  the  examples  alluded  to,  be- 
lieves that  the  dislocation  is  never  complete. 


Fig.  285. 


Fig.  286. 


Dislocations  of  the  lower  end  of  tibia  backwards. 


Eeduction  should  be  attempted  by  a  method  similar  to  that  which 
has  been  recommended  in  all  the  other  dislocations  of  the  ankle ;  only 
with  such  modifications  as  the  peculiarities  of  the  case  must  necessa- 
rily suggest. 


CHAPTER    XX. 

DISLOCATIONS  OF  THE   UPPER  END   OF  THE  FIBULA. 

Syn. — "Luxations  of  the  superior  peroneo-tibial  articulation  ;"  Malgaigne. 

Surgeons  have  frequently  described  a  condition  of  the  peroneo-tibial 
articulation,  in  which  the  ligaments  have  become  relaxed,  giving  a 
preternatural  mobilitj'  to  the  head  of  the  bone.  It  is  also  not  unfre- 
quently  displaced  upwards,  in  consequence  of  an  oblique  fracture  of 
the  tibia.  I  have  myself  seen  several  examples  of  both  these  acci- 
dents ;  but  simple  traumatic  dislocations,  which  can  only  occur  for- 
wards or  backwards,  are  very  rare. 


§  1.  Dislocations  of  the  Upper  End  op  the  Fibula  Forwards. 

Malgaigne  has  collected  three  examples  of  this  luxation,  uncom- 
plicated with  any  other  accident,  and  not  apparently  due  to  any  ab- 


UPPEE    EXD    OF    THE    FIBULA    BACKWARDS.  695 

norma]  condition  of  the  ligaments,  two  of  Avhich  at  least  seemed  to 
have  been  produced  by  the  violent  action  of  the  muscles  which  are 
attached  to  the  anterior  face  of  the  fibula.  The  third  example,  re- 
ported bj  Thompson,  in  the  London  Lancet^  permits  a  doubt  as  to 
whether  the  displacement  was  occasioned  by  muscular  action,  or  by  a 
direct  blow  upon  the  part. 

The  signs  which  characterize  the  anterior  luxation  are  the  absence 
of  the  head  of  the  fibula  in  its  natural  position,  and  its  presence  in 
front,  near  the  ligamentum  patellse ;  the  altered  direction  of  the  bi- 
ceps flexor  cruris  muscle ;  and,  in  one  case,  considerable  deformity  in 
the  shape  and  position  of  the  leg  has  been  observed. 

Thompson  and  Jobard  were  unable  to  accomplish  the  reduction 
while  the  leg  was  extended  upon  the  thigh,  but  succeeded  readily 
after  having  flexed  the  leg.  On  the  other  hand,  Savournin  succeeded 
with  the  leg  extended,  but  with  the  foot  flexed  upon  the  leg.  Mal- 
gaigne,  to  whom  I  am  indebted  for  these  observations,  thinks  that 
flexion  of  the  leg,  combined  with  flexion  of  the  foot,  would  render 
the  reduction  more  easy. 

In  whatever  position  the  limb  is  placed,  the  surgeon  must  rely 
chiefly  upon  forcible  pressure  made  with  the  fingers  against  the  front 
and  upper  portion  of  the  displaced  bone. 

J.  E.  Hawley,  of  Ithaca,  N.  Y.,  a  distinguished  practitioner,  and  late 
Prof,  of  Surgery  in  the  Geneva  Medical  College,  has  furnished  me 
with  a  brief  account  of  a  case  which  came  under  his  own  observation. 

On  the  29th  of  March,  1854,  Bambak,  while  vaulting  upon  the 
parallel  bars  in  a  gymnasium,  unintentionally  made  a  complete  somer- 
set, and  fell  with  his  right  foot  upon  the  edge  of  a  plank.  Dr.  Hawley, 
who  was  immediately  called,  found  his  right  leg  demi-flexed  and  im- 
movably fixed.  The  head  of  the  fibula  was  plainly  felt  in  front  of 
its  natural  position,  near  the  ligamentum  patella.  The  patient  was 
suffering  the  most  intense  pain.  Extension  and  counter-extension 
were  made,  and  while  the  doctor  was  pressing  with  both  of  his  thumbs 
upon  the  head  of  the  fibula,  it  went  into  its  place  with  an  audible  snap. 
The  relief  was  instantaneous.  Complete  rest  was  observed  for  a  few 
days,  while  cooling  lotions  were  constantly  applied,  and  within  a  week 
he  was  able  to  attend  to  his  usual  duties. 


§  2.  Dislocations  of  the  Upper  End  of  the  Fibula  Backwards. 

Sanson  has  recorded  one  example,  in  which  the  passage  of  the 
wheel  of  a  carriage  across  the  upper  part  of  the  leg,  precisely  on  a 
level  with  the  peroneo-tibial  articulation,  ruptured  the  ligaments  which 
bind  the  fibula  to  the  tibia,  and  caused  a  displacement  which,  however, 
seems  to  have  been  spontaneously  overcome.  Nevertheless  there  re- 
mained a  preternatural  mobility,  permitting  the  fibula  to  be  pushed 
easily  backwards  or  forwards  upon  the  tibia. 

The  only  example  of  a  permanent  backward  displacement  is  related 

1  Op.  cit.,  1850,  Tol.  i.  p.  385. 


696  INFERIOR    PERONEO-TIBIAL    DISLOCATIONS. 

by  Dubreuil.  A  man,  aet.  32,  in  order  to  save  himself  from  falling, 
sprang  suddenly,  with  his  right  leg  in  a  position  of  extreme  abduction, 
and  at  the  same  moment  he  experienced  a  severe  pain  in  the  region 
of  the  peroneo-tibial  articulation.  The  head  of  the  fibula  was  found 
to  be  thrown  backwards,  and  formed  under  the  skin  a  marked  promi- 
nence ;  the  foot  was  drawn  outwards,  and  the  whole  outside  of  the 
limb  became  cold  and  numb.  Dubreuil  flexed  the  leg  moderately, 
and,  pressing  the  head  of  the  fibula  from  behind  forwards,  the  reduc- 
tion was  easily  effected.  On  the  following  day,  the  limb  having  been 
straightened,  the  dislocation  was  found  to  be  reproduced.  It  was 
again  replaced,  and  the  knee  covered  with  a  leather  cap,  secured 
moderately  tight.  After  twelve  days  of  complete  rest,  the  knee  was 
moved  gently,  and  on  the  seventeenth  day  the  patient  walked  with 
the  help  of  a  cane.  For  some  time  the  leg  had  a  tendency  to  incline 
outwards;  but -in  about  three  months  the  cure  was  perfectly  esta- 
blished.^ 

It  is  probable  that  in  this  case  the  dislocation  resulted  from  the 
violent  action  of  the  biceps  flexor  cruris.  Such  at  least  is  the  opinion 
of  both  Dubreuil  and  Malgaigne,  and  I  see  no  reason  to  question  the 
correctness  of  their  theory. 


CHAPTER    XXI. 

DISLOCATIONS    OF    THE   INFERIOR   PERONEO-TIBIAL 
ARTICULATION. 

Nblaton  relates  the  only  example  of  a  simple  luxation  of  this  ar- 
ticulation of  which  we  have  any  information.  The  patient  who  was 
the  subject  of  this  accident,  presented  himself  at  the  hospital  under  the 
care  of  M.  Gerdy  on  the  thirty-ninth  day  after  the  accident,  which  had 
been  occasioned  by  the  passage  of  the  wheel  of  a  carriage  obliquely 
across  the  leg  in  such  a  manner  as  to  push  the  malleolus  externus 
directly  backwards.  The  lower  end  of  the  fibula  was  in  almost  direct 
contact  with  the  outer  margin  of  the  tendo-Achillis ;  the  outer  face  of 
the  astragalus,  abandoned  by  the  fibula,  could  be  distinctly  felt  in 
nearly  its  whole  extent;  the  foot  preserved  its  natural  position;  and 
he  could  walk  pretty  well,  only  that  he  was  obliged  to  step  with  some 
care.  M.  Gerdy  believed  that  the  bone  was  too  firmly  fixed  in  its  new 
position  to  be  moved,  and  therefore  made  no  attempt  at  reduction. 

'  Malgaigne,  op.  cit.,  torn.  ii.  p.  386. 


DISLOCATIONS    OF    THE    ASTEAGALUS. 


697 


CHAPTER   XXII. 


TARSAL    LUXATIONS. 


§  1.  Dislocations  of  the  Astragalus. 

Malgaigne,  who  speaks  also  of  luxations  "sub-astragaloid,"  has 
thought  proper  to  call  the  dislocations  which  we  now  propose  to 
consider  "  double  dislocations  of  the  astragalus."  In  the  variety  first 
named,  the  astragalus  retains  its  connections  with  the  tibia,  but  sepa- 
rates from  the  scaphoid  bone,  while  its  relations  to  the  calcaneum 
are  only  slightly  disturbed.  This  we  prefer  to  regard  as  one  of  the 
many  varieties  of  tarsal  luxations,  and  shall  appropriate  to  it  no  spe- 
cific appellation,  except  to  designate  it  as  astragalo-scaphoid,  or  astra- 
galo-calcaneo-scaphoid,  according  as  more  or  less  of  the  several  articu- 
lations are  disturbed. 

In  the  second  named  variety,  called  by  Malgaigne  a  "  double"  luxa- 
tion, and  which  constitutes  the  subject  of  this  chapter,  the  astraga- 
lus abandons  all  the  articular  surfaces  against  which  it  is  naturally 
applied,  and  thrusts  itself  out  from  between  the  tibia,  fibula,  cal- 
caneum, and  scaphoides ;  so  that  it  may  be  said  to  have  suffered  a 
triple  or  quadruple  rather  than  a  "double"  dislocation,  as  is  implied 
by  the  nomenclature  adopted  by  Malgaigne.  This  we  choose  to  regard 
as  the  only  true  dislocation  of  the  astragalus,  and  as  such  we  propose 
to  designate  it  by  the  simple  term  "dislocation  of  the  astragalus." 

The  astragalus  may  be  dislocated  forwards,  outwards,  inwards,  back- 
wards; or  it  may  be  dislocated  obliquely  in  either  of  the  diagonals 
between  these  lines;  it  may  be  simply  rotated  upon  its  lateral  axis 
without  much,  if  any,  lateral  displacement ;  and,  finally,  it  has  been 
occasionally  driven  be- 
tween the  tibia  and 
fibula,  tearing  away  the 
intermediate  ligaments, 
and  generally  fracturing 
one  or  both  bones  of  the 
leg. 

Causes. — The  causes 
which  have  been  found 
chiefly  operative  in  the 
production  of  this  dislo- 
cation are  very  much  the 
same  as  those  which  pro- 
duce, under  other  circum- 
stances, a  dislocation  of  the  lower  end  of  the  tibia.  Thus,  afall  from 
a  height  upon  the  bottom  of  the  foot,  accompanied  with  a  violent  ab- 


Fig.  287. 


Dislocation  of  astragalus  outwards.     Anatomical  relations. 


698 


TAESAL    LUXATIONS. 


due  lou,  adduction,  flexion,  or  extension,  may  determine  a  dislocation 
ot  the_  astragalus  inwards,  outwards,  backwards,  or  forwards  Some- 
times it  is  accomplished  bj  a  mere  wrenching  and  twisting,  of  the  foot 
in  machmerj,  or  in  the  wheel  of  a  carriage,  or  by  being°  caught  be- 
tween two  irregular  bodies.  It  may  be  produced  also  by  a^direc^t  blow. 
n?fiT}!Z  l^'^^l  prominence  occasioned  by  the  displacement 

rfntw^r'  '°  e^^^erf  these  several  directions,  accompanied  gene- 
ral y  with  more  or  less  lateral  deviation  of  the  foot,  is  alone  sufficient 
to  indicate  the  true  nature  of  the  accident.  In  some  cases,  also,  the 
foot  is  forcibly  flexed  or  extended;  the  leg  is  shortened  in  conse- 
quence of  the  tibia  having  fallen  down  upon  the  calcaneum  ;  the  super- 
mcumbent  skin  and  tendons  are  rendered  tense;  blood  is  effused,  and 

orthelo?''^^^^  "'^r-i  ^^  ^^\backward  dislocation,  the  position 
ot  the  foot  IS  not  much  changed,  but  the  tibia  being  slightly  carried 

dTm'nLh^cl         "^     "^  '^"  ^''''^  ''^'''  '^  '^'  ^"°^'«  proportionably 


Fig.  288. 


Fig.  289. 


Simple  dislocation  of  the  astragalus  oatwards. 


Compound  dislocation  of  the  astragalus  inwards. 


Such  are  the  symptoms  which  plainly  enough  indicate  the  dislo- 
cation in  the  most  simple  cases ;  but  in  a  majority  of  the  examples 
which  have  been  seen,  the  integuments  have  been  more  or  less  exten- 
sively torn,  exposing  to  the  eye  at  once  the  naked  bone,  and  thus 
removing  all  chance  of  error  in  the  diagnosis. 

Norris  mentions  a  case,  seen  by  Hammersley,  in  which  the  astra- 
galus was  thrown  completely  out,  and  was  subsequently  found  in  the 
earth  where  the  patient  had  received  his  injury.  Inflammation,  gan- 
grene and  tetanus  supervened,  and  the  patient  died  on  the  seventh  day.^ 

'  Norris,  Amer.  Journ.  Med.  Sci.,  Aug.  1837,  p.  383. 


DISLOCATIONS    OF    THE    ASTEAGALUS.  699 

Prognosis. — It  will  be  readily  understood  that  nothing  short  of  very 
great  violence  could  disturb  and  completely  break  up  the  connections 
of  a  bone  so  compactly  and  firmly  seated  as  is  the  astragalus,  and  that 
aside  of  any  unusual  complications,  under  the  most  favorable  cir- 
cumstances, intense  inflammation  must  naturally  be  anticipated;  and 
with  few  exceptions  this  has  actually  taken  place.  Even  when  reduc- 
tion has  been  promptly  and  easily  effected,  inflammation,  gangrene, 
and  death  have  sometimes  speedily  ensued.  But  more  often  the  re- 
duction has  been  found  to  be  exceedingly  difficult  or  impossible,  and 
complete  removal  of  the  bone  or  amputation  has  been  immediately 
demanded. 

In  a  limited  number  of  cases,  on  the  other  hand,  the  bone  has  been 
easily  reduced,  and  recovery  has  taken  place  with  a  tolerably  useful 
limb  ;  or  resection  has  been  practiced  with  an  equally  favorable  result ; 
in  still  other  cases  the  bone  has  been  left  protruding,  and  the  patient 
has  finally  recovered  so  far  as  to  be  able  to  walk  again,  but  in  such 
a  crippled  condition  as  to  render  the  achievement  a  very  doubtful 
triumph  of  conservative  surgery. 

Norris,  of  Philadelphia,  relates  the  following  case,  illustrating  the 
imminent  danger  to  which  even  the  life  of  the  patient  may  be  ex- 
posed in  those  examples  which  are  apparently  the  most  simple. 

William  Summerill,  «t.  80,  was  admitted  to  the  Pennsylvania 
Hospital  on  the  twenty-sixth  of  September,  1831.  An  hour  previous, 
while  descending  a  ladder,  he  slipped  and.  fell  in  such  a  manner  as  to 
throw  the  entire  weight  of  his  body  upon  the  outer  part  of  his  left 
foot.  The  foot  was  turned  inwards,  and  nearly  immovable;  a  slight 
depression  existed  immediately  below  the  lower  end  of  the  tibia,  and 
there  was  a  hard  rounded  projection  on  the  outer  part  of  the  foot  a 
little  below  and  in  front  of  the  extremity  of  the  fibula ;  the  skin  over 
this  projection  was  not  broken  or  excoriated,  but  reddened;  there  was 
no  fracture  of  either  bone  of  the  leg. 

The  symptoms  rendered  it  plain  that  the  astragalus  was  dislocated 
forwards  and  outwards.  Dr.  Barton,  under  whose  care  the  patient 
was  received,  proceeded  soon  after  to  make  attempts  at  reduction. 
The  muscles  of  the  leg  were  relaxed,  as  much  as  possible,  and  exten- 
sion made  from  the  foot  by  seizing  the  heel  and  front  part  of  the  foot 
while  an  assistant  made  counter-extension  at  the  knee.  The  bone 
was  also  pushed  inwards  toward  the  joint  by  the  surgeon.  These 
efforts  were  continued  for  a  considerable  time,  but  had  no  effect  in 
changing  the  position  of  the  bone. 

Six  hours  afterwards,  Drs.  Harris  and  Hewson  being  in  consultation, 
the  attempt  was  again  made  to  accomplish  the  reduction,  but  without 
success ;  and  the  surgeons  immediately  proceeded  to  excise  the  bone. 

An  incision  was  made  parallel  with  the  tendons,  commencing  a 
short  distance  above  the  projection  and  extending  down  far  enough 
to  expose  fairly  the  astragalus  and  its  torn  ligaments.  The  bone  was 
then  seized  with  the  forceps  and  easily  removed  after  the  division  of 
a  few  ligamentous  fibres  that  continued  to  connect  it  with  the  adjoin- 
ing parts.  Very  little  bleeding  occurred,  only  two  small  arteries 
requiring  the  ligature. 


700  TAESAL    LUXATIONS. 

After  removal,  it  was  discovered  that  about  oae-half  of  the  surface 
which  plays  in  the  lower  end  of  the  tibia  had  been  fractured,  and  that 
it  remained  firmly  attached  to  the  extremity  of  that  bone.  No  attempt 
was  made  to  remove  this  fragment;  but  the  joint  being  carefully 
sponged  out,  the  sides  of  the  wound  were  brought  together  and  closed 
by  sutures,  adhesive  straps  and  a  roller;  after  which  the  foot,  placed 
in  its  natural  position,  was  laid  in  a  fracture-box. 

On  the  fifth  day  a  slough  began  to  form  upon  the  outside  of  the 
foot,  which  was  followed  by  suppuration  at  other  points,  and  on  the 
thirteenth  day  an  opening  was  made  to  evacuate  the  pus  near  the 
malleolus  internus.  At  the  end  of  about  eight  weeks  the  fragment  of 
the  astragalus  which  had  been  suffered  to  remain,  was  found  to  be 
carious,  and  it  was  removed  ;  the  heel  also  had  ulcerated  from  pressure, 
and  several  other  bones  of  the  tarsus  were  discovered  to  be  carious. 
Fifteen  months  later,  this  poor  fellow  was  still  in  the  hospital  suffering 
from  hectic,  with  extensive  disease  in  the  bones  of  the  tarsus  and  ankle- 
joint.  Finally,  amputation  of  the  leg  was  practiced  by  Dr.  Barton,  a 
few  days  after  which  he  died.^ 

Norris  mentions  also  two  examples  of  simple  dislocation  of  the 
astragalus  at  the  Pennsylvania  Hospital  which  came  under  the  obser- 
vation of  Dr.  Barton,  in  both  of  which  the  bone  was  left  unreduced. 
In  one  case  inflammation  and  sloughing  soon  effected  a  complete  ex- 
posure of  the  protruding  bone,  but  after  a  time  the  skin  cicatrized. 
At  the  end  of  five  months  the  patient  walked  and  had  good  use  of  the 
joint,  though  great  deformity  of  the  foot  existed,  and  he  continued  to 
be  subject  to  ulceration  of  the  newly-formed  skin  on  its  outer  part. 
In  the  other  case  gangrene  supervened  soon  after  the  accident,  and 
the  patient  died. 

Norris  adds  that  "the  late  Professor  Wistar  removed  the  astragalus 
in  a  case  of  compound  dislocation,  and  the  patient  was  cured  with 
some  motion  at  the  joint." 

Dr.  Alexander  Stevens,  of  New  York,  made  the  same  operation  in 
a  case  of  compound  dislocation,  and  after  several  months,  he  affirms 
that  the  patient  "  has  recovered  with  very  trifling  deformity  of  the 
foot,  and  with  a  flexible  joint.     He  walks  with  very  slight  lameness."^ 

The  dislocations  backwards,  of  which  seven  examples  only  have 
been  recorded,  have  all  with  but  one  exception  been  left  unreduced; 
yet  in  at  least  four  instances  the  patients  have  recovered  with  pretty 
useful  limbs.  Such  was  the  fact  with  Listen's  and  Lizars'  patients,  and 
also  with  Mr.  Phillips'  two  cases,  to  all  of  which  I  shall  again  refer. 
It  must  be  noticed,  however,  that  in  each  of  the  cases  mentioned  as 
followed  by  a  successful  termination  without  reduction,  the  disloca- 
tions were  simple. 

Turner,  of  Manchester,  has  reported  one  example  of  compound  luxa- 
tion outwards  and  backwards,  which,  finding  himself  unable  to  reduce, 
he  removed  the  astragalus  with  a  tolerably  successful  result.^    F'inally 

'  Norris,  Amer.  Journ.  Med.  Sci.,  Aug.  1837,  p.  378. 
^  Stevens,  North  Amer.  Med.  and  Surg.  Journ.,  Jan.  1827,  p.  200. 
*  Turner,  Trans.  Provin.  Med.  and  Surg.  Journ.,  vol.  ix.  Essay  on  Disloc.  of  Astrag. 
with  nearly  fifty  cases. 


DISLOCATIONS    OF    THE    ASTRAGALUS.  701 

a  case  was  presented  in  one  of  the  London  hospitals  in  1839,  of  a 
dislocation  inwards  and  backwards,  which  was  reduced  in  about  ten 
minutes,  by  extension  accompanied  with  lateral  pressure.' 

Treatment. — Various  attempts  have  been  made  by  surgical  writers 
to  determine  the  line  of  treatment  which  should  be  adopted  in  these 
unfortunate  cases,  but  with  very  unsatisfactory  results,  since  they  are 
far  from  having  arrived  at  similar  conclusions,  nor  have  they  been 
able  always  to  settle  the  question  definitely  for  themselves.  The 
difficulty  consists  in  the  multiplicity,  and  lack  of  uniformity  in  the 
complications  which  attend  these  accidents,  rendering  it  impossible 
to  establish  a  classification  upon  which  an  uniform  treatment  may  be 
safely  based.  There  are  certain  principles,  however,  which  seem  to  be 
sufficiently  settled  to  allow  of  an  authoritative  announcement;  these 
may  be  briefly  stated  as  follows:  If  the  dislocation  is  simple,  reduce 
the  astragalus  immediately,  provided  this  is  possible.  If  the  luxation 
is  complete,  and  it  cannot  be  reduced,  even  partially,  proceed  at  once 
to  resection  or  to  amputation.  In  compound  dislocations,  resection 
or  amputation  affords  the  only  safe  resource.  In  all  cases  the  inflam- 
mation is  likely  to  be  intense,  in  order  to  prevent  which  complica- 
tion the  surgeon  must  be  unremitting  in  his  use  of  the  appropriate 
remedies. 

Out  of  eighteen  cases  of  complete  excision  of  the  astragalus,  collected 
by  Turner,  fourteen  made  good  recoveries,  and  in  only  one  of  these 
fourteen  was  there  anchylosis. 

These  several  points  we  shall  proceed  to  illustrate  a  little  more 
fully. 

In  a  recent  simple  luxation  of  the  astragalus  forwards,  the  leg 
should  be  flexed  to  a  right  angle  with  the  thigh,  and  for  the  purpose 
of  making  extension,  one  assistant  should  take  hold  of  the  foot  with 
both  hands  in  the  same  manner  that  a  servant  draws  a  boot,  that  is, 
with  the  right  hand  grasping  the  heel,  and  the  left  placed  upon  the 
dorsum  of  the  foot  near  the  toes.  A  second  assistant  should  seize  the 
lower  part  of  the  thigh  in  order  to  make  counter-extension,  while  the 
surgeon  presses  with  the  ball  of  his  hand  against  the  head  of  the  as- 
tragalus, upwards  and  backwards.  If  these  simple  measures  fail,  the 
pulleys  ought  to  be  employed  as  a'  substitute  for  the  hands  in  making- 
extension.  In  applying  the  extension,  the  toes  must  be  kept  well 
down,  and  occasionally  the  foot  should  be  moved  gently  from  one  side 
to  the  other. 

An  oblique  dislocation  must  be  reduced,  if  possible,  to  an  anterior 
luxation,  before  an  attempt  is  made  to  carry  the  head  of  the  bone  back 
to  its  place,  as  by  this  mode  the  reduction  will  be  greatly  facilitated. 

Lateral  luxations  may  be  reduced  by  the  same  means;  but  if  the 
astragalus  is  dislocated  outwards  the  foot  must  be  held  forcibly  ad- 
ducted  during  the  extension,  and  if  it  is  dislocated  inwards,  the  foot 
must  be  held  strongly  in  the  opposite  direction. 

Lizars  says  that  he  has  seen  one  case  of  backward  luxation,  and 
that  all  attempts  at  reduction  were  unavailing.     The  limb  was,  how- 

'  Loudon  Lancet,  voL  ii.  p.  559. 


702  TARSAL    LUXATIONS. 

over,  preserved  and  proved  to  be  useful.^  Liston  was  eqiially  un- 
successful in  a  case  whicli  came  under  his  notice.^  Phillips  has 
reported  two  cases,  in  neither  of  which  was  the  reduction  accom- 
plished.^ Ndlaton  has  seen  a  compound  dislocation  which  he  could 
not  reduce,''  Mr.  Erichsen,  however,  who  admits  that  when  dislocated 
backwards  it  has  not  hitherto  been  reduced,  declares  that  the  surgeons 
at  University  Hospital  have  succeeded  in  one  case  recently,  in 
which  both  the  tibia  and  fibula  were  broken  also.^  Mr.  Erichsen 
suggests  also  that  in  case  of  a  failure  by  the  ordinary  means,  we 
should  resort  to  a  subcutaneous  section  of  the  tendo-Achillis.  Mr. 
Williams,  of  Dublin,  in  a  similar  case,  which  had  been  left  unreduced, 
was  obliged  finally  to  extract  the  bone,  in  consequence  of  the  integu- 
ments having  sloughed.^ 

Compound  dislocations,  and  such  as  are  otherwise  complicated, 
demand  of  the  surgeon  immediate  amputation,  or  exsection,  the  latter 
of  which  ought  to  be  preferred  whenever  the  condition  of  the  limb 
encourages  a  reasonable  hope  that  the  foot  may  be  saved. 

When  exsection  is  pi'acticed,  and  the  bone  is  found  to  be  broken, 
as  it  often  is,  all  the  fragments  should  be  carefully  removed,  since 
they  are  certain  to  become  necrosed  if  left  in  place.  Nor  ought  the 
surgeon  to  hesitate  to  lay  open  freely  the  tissues  in  every  direction,  in 
order  that  he  may  accomplish  this  purpose ;  even  the  tendons  lying 
over  the  protruding  bone  may  be  sacrificed  unhesitatingly,  since  after 
havifig  been  so  severely  bruised,  stretched,  and  lacerated,  they  are 
pretty  certain  to  slough.  Indeed  the  more  freely  the  tissues  are 
divided  over  the  bone,  the  less  will  be  the  danger  of  inflammation, 
and  the  safer  will  be  the  life  and  limb  of  the  patient. 

In  addition  to  the  examples  already  cited  of  compound  dislocation 
in  which  the  astragalus  was  removed,  the  following,  reported  by  Dr. 
W.  A.  Gillespie,  of  Ellisville,  Va.,  will  also  illustrate  the  occasional 
value  of  exsection  in  these  severe  accidents. 

Mrs.  A.,  aged  about  fifty  years,  fell  from  a  horse  on  the  23d  of  May, 
1888,  dislocating  both  ankles.  The  luxation  of  the  right  foot  was 
accompanied  with  a  luxation  of  the  astragalus  outwards,  which  pro- 
jected through  a  very  large  wound  in  the  integuments,  and  its  trochlea 
was  placed  at  an  angle  of  about  45°  with  its  natural  position.  Early 
on  the  following  day  it  was  removed  by  severing  its  few  remaining 
connections,  and  the  wound  was  immediately  closed  by  stitches,  ad- 
hesive plasters,  and  light  dressings.  From  the  moment  of  the  receipt 
of  the  injury,  and  for  several  days  afterwards,  she  suffered  excruciating 
pain  in  the  limb,  and  on  the  third  day  tetanus  was  apprehended,  but 
Its  full  accession  was  prevented  by  the  free  use  of  opiates.  The  limb 
was  suspended  in  N.  R.  Smith's  fracture  apparatus;  and  as  gangrene 
with  hectic  fever  soon  threatened  the  life  of  the  patient,  fermenting 

■  Lizars,  System  of  Practical  Surg.,  Edinburgh  ed.,  1847,  p.  161. 

^  Liston,  Elements  of  Surgery,  vol.  iii.  p.  848. 

3  Phillips,  Lond.  Med.  Gaz.,  vol.  xiv.  p.  596. 

■■  Nelaton,  Pathologie  Chirurg.,  t.  ii.  p.  482. 

^  Erichsen,  Science  and  Art  of  Surg.,  Amer.  ed.,  1859,  p.  270. 

*  Williams,  Erichsen,  op.  cit.,  p.  271. 


ASTRAGALO-CALCANEO-SCAPHOID    DISLOCATIONS.        703 

poultices  were  diiigentlj  applied,  and  the  patient  was  sustained  by 
wine,  bark,  and  other  tonics.  Two  months  after  the  injury  was  re- 
ceived, the  date  at  which  the  report  is  given,  the  wound  had  entirely 
healed,  and  her  complete  recovery  was  regarded  as  certain.^  Many 
other  similar  examples  have  been  reported  by  foreign  surgeons. 

One  word  more  with  regard  to  the  treatment  of  the  wound  after 
excision.  A  considerable  experience  in  accidents  and  wounds  of  this 
class,  that  is,  wounds  accompanied  with  great  contusion  and  lacera- 
tion, has  convinced  me  that  the  practice  of  closing  the  surface  with 
sutures,  adhesive  plasters,  bandages,  &c.,  is  eminently  pernicious. 
The  effusions,  which  must  necessarily  occur,  and  which  indeed  we 
think  ought  to  occur,  are  thus  imprisoned  beneath  the  skin,  giving 
rise  to  swelling,  pain,  inflammation,  and  finally  suppuration  or  slough- 
ing. It  is  far  better,  in  our  opinion,  to  have  the  wound  open,  covering 
it  only  with  cloths  constantly  kept  moist  with  cool  water.  For  this 
latter  purpose  some  mode  of  irrigation  is  preferable,  as  being  more  con- 
stant and  uniform.  To  those  who  have  never  adopted  this  treatment 
of  contused  wounds,  or  of  wounds  generally,  we  would  recommend  an 
early  trial,  feeling  confident  that  they  will  never  have  occasion  to 
regret  the  experiment. 


§  2.  Astragalo-Calcaneo-Scaphoid  Dislocations. 

It  is  perhaps  quite  as  common  for  the  astragalus  to  be  dislocated 
from  the  scaphoid  bone  and  calcaneum,  while  it  retains  its  connec- 
tions with  the  tibia,  as  to  be  luxated  from  all  these  bones  at  the 
same  time.  This  astragalo-calcaneo-scaphoid  dislocation  is  that  which 
Malgaigne  has  termed  "  sub-astragaloid."  Produced  by  the  same 
causes  which  determine  true  dislocations  of  the  astragalus,  it  may 
occur  in  the  same  directions,  and  is  liable  to  the  same  complications ; 
nor  will  either  the  prognosis  or  treatment  differ  essentially  from  that 
which  is  recognized  and  established  in  the  other  accident. 

As  in  dislocations  proper  of  the  astragalus,  so  also  in  this  accident, 
opposite  results  have  occasionally  followed  from  similar  modes  of  treat- 
ment. Thus,  Dr.  Detrnold,  of  New  York,  stated  in  1856  to  the  New 
York  Academy  of  Medicine,  that  he  had  recently  met  with  a  dislocation 
of  the  astragalus,  in  which  the  bone  retained  its  proper  relations  with 
the  tibia,  but  not  with  the  bones  of  the  tarsus.  The  patient  had  fallen 
from  a  wagon  and  caught  his  foot  in  the  wheel.  Dr.  Detmold  made 
extension  with  pulleys,  but  could  not  effect  the  reduction.  Subse- 
quently he  was  obliged  to  remove  the  astragalus  on  account  of  the 
suppuration  which  followed  and  the  consequent  exposure  of  the  bone. 
The  wound  did  not  heal  kindly,  and  at  length  amputation  of  the  leg 
became  necessary. 

Dr.  Detmold  concludes,  from  this  example  and  others  which  have 
come  to  his  knowledge,  that  if  a  similar  case  were  to  present  itself  to 
him  again,  he  would  amputate  at  once.' 

1  Gillespie,  Amer.  Journ.  Med.  Sci.,  Aug.,  1833,  p.  552. 

2  Detmold,  New  York  Journ.  Med.,  May,  1856,  p.  383. 


704  TAESAL    LUXATIONS. 

The  following  case,  reported  by  Dr.  Thomas  Wells,  of  Columbia, 
S.  C,  is  of  unususl  interest,  as  illustrating  the  danger  of  leaving  the 
bone  displaced,  and  also  the  benefit  which  may,  even  under  the  most 
unfavorable  circumstances,  result  from  its  final  removal. 

Doctor  S.,  8et,  30,  was  riding  in  an  open  carriage,  some  time  during 
the  37ear  of  1819,  when  his  horses  became  frightened  and  ran,  and  in 
leaping  from  his  vehicle  he  struck  upon  his  left  foot,  dislocating  the 
astragalus  from  its  junction  with  the  scaphoid  bone,  upwards  and 
slightly  outwards.  Several  medical  gentlemen  made  violent  efforts  to 
reduce  the  bone,  but  without  effect.  Inflammation  and  suppuration, 
accompanied  by  a  high  fever,  soon  followed,  and  the  head  of  the  astra- 
galus becoming  carious,  protruded  through  the  skin.  On  the  18th  of 
August,  about  seven  months  after  the  injury  was  received,  he  was  still 
suffering  from  a  copious  discharge,  pain,  swelling,  and  general  irrita- 
tive fever,  and  it  was  determined  to  excise  the  bone;  which  was 
accordingly  done  by  enlarging  the  wound  and  detaching  its  loose  con- 
nections with  the  adjacent  tissues.  The  astragalus  extracted  left  a 
frightful  wound,  the  foot  seeming  to  be  nearly  separated  from  the  leg, 
A  hollow  splint  was  adjusted  to  the  inside  of  the  foot  and  leg,  so  as  to 
preserve  the  limb  perfectly  steady  and  in  a  proper  direction ;  simple 
dressings  were  applied,  and  an  anodyne  administered  internally. 
No  accidents  followed,  and  at  the  end  of  September  the  wound  was 
healed,  and  the  swelling  of  the  parts  had  entirely  subsided.  One 
year  after  the  operation,  he  walked  without  the  least  difficulty  ;  the 
ankle  being  then  "perfectly  sound."  The  leg  was  shortened  about 
one  inch,  and  this  deficiency  was  supplied  by  a  thick  heel  upon  his 
shoe,^ 

Examples  might  be  cited  illustrative  of  the  value  of  early  exsection  i 
where  reduction  could  not  be  accomplished ;  but  after  what  has  | 
already  been  said  upon  the  subject  of  dislocations  of  the  astragalus, 
we  shall  not  regard  any  farther  references  as  either  necessary  or  use- 
ful. If  other  principles  of  treatment  are  to  govern  the  surgeon  than 
those  which  we  have  already  laid  down,  they  cannot  here  be  stated. 
They  are  among  those  unwritten  rules  whose  existence  we  cannot 
always  recognize  until  the  case  arises  upon  which  they  may  apply. 
Yet  in  the  exigency  supposed  they  are  as  clearly  defined,  and  as  im- 
perative, in  the  mind  of  the  clever  surgeon,  as  any  of  those  laws  which 
have  been  made  the  subjects  of  special  record. 

§  3.  Dislocations  of  the  Calcaneum.  m 

The  calcaneum  may,  as  a  consequence  of  a  fall  upon  the  heel,  or  of 
a  direct  blow,  be  dislocated  outwards  from  the  astragalus  alone,  or 
upwards  and  outwards  from  the  cuboid  bone  at  the  same  time.  It 
has  been  found  also  at  the  same  moment  dislocated  outwards  from  the 
astragalus,  and  inwards  upon  the  cuboid  bone. 

Ohelius  says  he  has  seen  an  old  dislocation  of  the  calcaneum,  pro- 
duced in  early  life  by  pulling  off'  a  boot;  from  which  there  finally 

'  Wells,  Amer.  Journ.  Med.  Sci.,  May,  1832,  p.  21. 


MIDDLE    TARSAL    DISLOCATION'S.  705 

resulted  a  degeneration  like  elephantiasis  of  the  leg,  rendering  ampu- 
tation necessary,^ 

Mr.  South  remarks  in  his  notes  to  Chelius,  that  the  two  cases  of 
dislocation  outwards  of  this  bone,  mentioned  by  Sir  Astlej  Cooper, 
were  from  his  (South's)  notes  (cases  199  and  200).  In  the  first  case, 
that  of  Martin  Bentley,  occasioned  by  the  falling  of  a  heavy  stone 
upon  his  foot,  tlie  integuments  were  not  broken,  and  the  position  of  the 
foot  resembled  a  varus.  "The  dislocation  was  easily  reduced,  having 
bent  the  thigh  and  knee  on  the  body  and  fixed  the  leg,  by  laying  hold 
of  the  metatarsus  and  of  the  tuberosity  of  the  heel-bone,  and  drawing 
the  foot  gently  and  directly  from  the  leg,  during  which  extension 
Cline  put  his  knee  against  the  outside  of  the  joint,  and  the  foot  being 
pressed  against  it,  the  heel  and  the  navicular  bone  readily  slipped 
into  their  place,  and  the  deformity  disappeared."  He  was  discharged 
from  the  hospital  in  five  weeks,  "  having  the  complete  use  of  his  foot." 

In  the  second  case,  the  dislocation,  produced  also  by  the  fall  of  a 
stone  upon  the  foot,  was  compound,  and  the  patient,  Thomas  Gilmore, 
having  been  brought  into  St.  Thomas's  Hospital,  the  reduction  was 
effected  by  extending  the  foot,  and  rotating  it  outwards.  Six  months 
aftei',  when  he  left  the  hospital,  he  was  able  to  walk  pretty  well  with 
a  stick. 


§  4.  Middle  Tarsal  Dislocations. 

The  scaphoid  and  cuboid  bones  may  be  dislocated  from  the  astra- 
galus and  calcaneum,  constituting  what  is  termed,  by  Malgaigne,  a 
middle  tarsal  dislocation.  It  is  probable  that  to  some  extent  the  same 
thing  has  occurred  in  many  of  those  cases  which  are  reported  as  sim- 
ple dislocations  of  the  astragalus,  or  as  dislocations  at  the  astragalo- 
scaphoid  articulation ;  but  it  occurs  also  occasionally  in  a  degree  so 
perfect  and  complete  as  to  leave  no  doubt  as  to  the  true  nature  of  the 
disjunction,  and  to  entitle  it  to  a  separate  consideration. 

Mr.  Liston  mentions  the  case  of  a  boy,  set.  14,  who  fell  from  a  height 
of  forty  feet,  striking,  apparently,  upon  the  extremity  of  the  foot. 
The  scaphoid  and  cuboid  bones  were  found  to  be  displaced  upwards 
and  forwards,  so  that  the  foot  was  shortened  about  half  an  inch,  and 
had  a  clubbed  appearance.  No  attempt  was  made  to  reduce  the  bones, 
and  he  left  the  hospital  in  three  weeks,  able  to  stand  on  the  foot.^  Sir 
Astley  Cooper  has  recorded  in  more  detail  a  similar  example.  A  man, 
working  at  the  Southwark  bridge,  London,  received  upon  the  top  of 
his  foot  a  stone  of  great  weight.  He  was  immediately  carried  to  Guy's 
Hospital,  and  his  condition  is  described  as  follows:  "The  os  calcis  and 
the  astragalus  remained  in  their  natural  situations,  but  the  fore  part 
of  the  foot  was  turned  inwards  upon  the  bones.  When  examined  by 
the  students,  the  appearance  was  so  precisely  like  that  of  a  club-foot, 
that  they  could  not  at  first  believe  but  that  it  was  a  natural  defect  of 
that  kind,"  but  upon  the  assurance  of  the  man,  that  previously  to  the 

1  Chelius,  System  of  Surg.,  Amer.  ed.,  vol.  ii.  p.  354. 

2  Practical  Surg.,  also  London  Lancet,  vol.  sxxvii.  p.  133. 
45 


706  TARSAL    LUXATIONS. 

accident  Tais  foot  was  not  distorted,  extension  was  made,  and  the  re- 
duction was  effected.  He  was  discharged  from  the  hospital  in  five 
weeks,  having  the  complete  use  of  his  foot.^ 


§  5.  Dislocations  of  the  Os  Cuboides. 

According  to  Piedagnel,  quoted  by  Chelius,  the  cuboid  bone  may 
be  dislocated  upwards,  inwards,  and  downwards,  but  Malgaigne  affirms 
that  he  has  found  no  case  recorded  in  which  the  dislocation  has  oc- 
curred alone,  or  unaccompanied  with  a  dislocation  of  one  or  more  of! 
the  other  tarsal  bones. 


§  6.  Dislocations  of  the  Os  Scaphoides. 

Burnett  has  seen  a  luxation  of  the  scaphoid  bone  in  which  its  con- 
nections with  the  astragalus  v/ere  undisturbed,  while  at  the  same  time 
it  was  completely  separated  from  the  cuneiform  bones.  By  strong 
pressure  exercised  during  several  minutes,  the  os  scaphoides  was 
made  to  fall  into  its  place.  The  dislocation  was  compound,  yet  the 
wound  healed  rapidly,  and  in  a  short  time  the  recovery  was  almost  com- 
plete.^ 

Several  examples  are  recorded  of  a  true  luxation  of  the  os  sca- 
phoides, in  which  the  bone  had  abandoned  both  the  astragalus  on  the 
one  hand,  and  the  cuneiform  bones  on  the  other, 

Piedagnel  mentions  a  case  in  which  the  scaphoid  bone  was  broken 
longitudinally,  and  its  internal  fragment,  constituting  the  largest  por- 
tion, was  displaced  inwards  through  a  tegumentary  wound.  He  was 
unable  to  eflect  reduction,  and  was  compelled  to  amputate  the  foot.^ 

Walker  has  reported  the  first  example  of  luxation  forwards,  occa- 
sioned by  jumping  upon  the  ball  of  the  foot.  The  bone  formed  a 
marked  projection  upon  the  top  of  the  foot,  and  a  corresponding,  de- 
pression existed  below.  An  attempt  was  first  made  to  accomplish 
the  reduction  by  simple  pressure  with  the  thumbs ;  but  this  having 
failed,  the  surgeon  bent  the  extremity  of  the  foot  forcibly  downwards, 
and  by  continuing  to  press  upon  the  os  scaphoides,  it  fell  into  its  posi- 
tion easily  and  with  a  distinct  click.  In  about  three  weeks  the  patient 
was  able  to  walk  with  only  a  slight  halt,  and  no  deformity  remained.'' 


§  T.  Dislocations  of  the  Cuneiform  Bones. 

The  cuneiform  bones  may  be  luxated  partially,  and  without  having 
separated  from  each  other,  of  which  two  or  three  examples  are  re- 
corded ;  or,  which  is  more  common,  the  cuneiforme  internum  may  be 
luxated  alone.     Says  Sir  Astley  Cooper:    "I  have  twice  seen  this 

'  Sir  A.  Cooper  on  Disloc,  &c.,  London  ed.,  1823,  p.  376. 
^  Burnett,  Lond.  Med.  Gazette,  1837,  voL  six.  p.  221. 
^  Piedagnel,  Journ.  Univ.  et  Heb.,  torn.  ii.  p.  208. 
*  Walker,  The  Medical  Examiner,  1851,  p.  203. 


DISLOCATIONS    OF    THE    CUNEIFORM    BONES.  707 

bone  dislocated  ;  once  in  a  gentleman  who  called  upon  me  some  weeks 
after  the  accident,  and  a  second  time  in  a  case  which  occurred  in 
Guy's  Hospital  very  lately.  In  both  instances  the  same  appearances 
presented  themselves.  There  was  a  great  projection  of  the  bone  in- 
wards, and  some  degree  of  elevation,  from  its  being  drawn  up  by  the 
action  of  the  tibialis  anticus  muscle ;  and  it  no  longer  remained  in  a 
direct  line  with  the  metatarsal  bone  of  the  great  toe.  In  neither  case 
was  the  bone  reduced;  the  subject  of  the  first  of  these  accidents 
walked  with  but  little  laalting,  and  I  believe  would  in  time  recover 
the  use  of  the  foot,  so  as  not  to  appear  lame.  The  cause  of  the  acci- 
dent was  a  fall  from  a  considerable  height,  by  which  the  ligament 
was  ruptured  which  connects  this  bone  with  the  os  cuneiforme,  and 
with  the  OS  naviculare.  The  second  case,  which  was  in  Gruy's  Hospital, 
my  apprentice,  Mr.  Babington  informs  me,  happened  by  the  fall  of  a 
horse,  and  the  foot  was  caught  between  the  horse  and  the  curb-stone."^ 

In  a  case  of  compound  luxation  seen  by  Mr.  Key,  reduction  was 
effected  and  in  two  months  the  cure  was  so  far  completed  that  the 
patient  walked  with  only  a  slight  lameness.^  Nelaton,  in  a  similar 
case  of  compound  luxation,  unable  to  reduce  the  bone,  removed  it 
completely,  and  the  patient  recovered.^ 

Robert  Smith  has  called  attention  to  a  species  of  dislocation  of  the 
internal  cuneiform  bone  not  before  very  accurately  described ;  but  of 
which  he  has  presented  two  examples.  It  consists  in  a  simultaneous 
dislocation  of  the  metatarsus  and  internal  cuneiform;  that  is  to  say, 
the  first  metatarsal  bone  together  with  the  internal  cuneiform  is 
dislocated  upwards  and  backwards  upon  the  tarsus,  carrying  with 
it  also  the  four  remaining  metatarsal  bones.  In  both  of  the  ex- 
amples seen  and  recorded  by  him,  the  dislocations  were  ancient,  and 
no  account  could  be  obtained  of  the  precise  manner  in  which  the 
accidents  had  been  produced.  The  feet  were  foreshortened  to  the 
extent  of  an  inch  or  more,  in  consequence  of  the  overlapping  of  the 
bones,  yet  the  heel  in  each  case  preserved  its  natural  relations  to  the 
tibia,  not  being  proportionately  lengthened  as  is  the  case  in  disloca- 
tions of  the  tibia  forwards.  The  plantar  surface  of  the  foot  was 
turned  inwards,  and  instead  of  being  concave  it  was  convex,  both  in 
its  antero-posterior  and  transverse  diameters.  A  transverse  ridge  on 
the  top  of  the  foot  also  indicated  the  line  of  the  projecting  bones. 
Both  of  these  cases  were  verified  by  a  careful  dissection.^ 

Dupuytren  has  reported  in  his  Treatise  on  Injuries  of  the  Bones,  a 
similar  case,  occurring  in  a  woman  get.  30,  who  was  brought  immedi- 
ately to  Hotel  Dieu.  She  stated  that  in  descending  from  the  _  bridge 
of  St.  Michael  with  a  burden  of  two  hundred  pounds,  she  fell  in  such 
a  way  that  the  whole  weight  of  the  body  was  received  on  the  right 
foot,  and  that  at  the  moment  she  made  an  effort  to  check  herself  in 
falling,  she  experienced  extremely  severe  pain  in  this  part,  and  heard 
a  very  distinct  snap  ;  she  was  unable  to  raise  herself  from  the  ground. 

1  Sir  Ast.  Cooper,  op.  cit.,  p.  383.         ^  ^ey,  Guy's  Hosp.  Rep.,  1836,  vol.  i.  p.  544. 

*  Nelaton,  Malgaigne,  op.  cit.,  p.  1076. 

*  Robert  Smith,  Treatise  on  Fractures,  &c.,  Dublin  ed.,  1854,  p.  224  et  seq. 


708  DISLOCATIONS    OF    THE    METATAESAL    BONES. 

On  the  following  morning  Dupuytren  reduced  the  bones  with  very 
little  difficulty  by  extension,  combined  with  pressure  against  the 
dislocated  ends.  The  bones  went  into  place  with  a  loud  snap,  and  in 
two  or  three  months  she  left  the  hospital  with  only  a  little  lameness.^ 
Mr.  Smith,  without  intending  to  question  the  possibility  of  a  simple 
luxation  of  the  metatarsal  bones,  of  which,  indeed,  Malgaigne  has 
collected  a  number  of  well  authenticated  examples,  is  inclined  to 
believe  that,  when  a  luxation  of  the  bones  of  the  metatarsus  is  the 
consequence  of  a  fall  from  a  height,  the  individual  alighting  upon  the 
anterior  part  of  the  foot,  it  is,  in  general,  that  variety  which  has  now 
been  described.  And  this  aptness  on  the  part  of  the  cuneiform  bone 
to  maintain  its  connection  with  the  first  metatarsal  bone,  he  would 
ascribe  mainly  to  the  fact  that  both  the  peroneus  longus  and  tibialis 
anticus  have  attachments  to  each  of  the  bones  in  question. 


CHAPTEE    XXIII, 

DISLOCATIONS   OF  THE  METATARSAL  BONES. 

Luxations  of  one  or  more  of  the  metatarsal  bones,  at  the  points 
of  their  articulations  with  the  tarsus,  have  been  known  to  occur  in 
almost  every  direction.  They  may  be  occasioned  by  crushing  acci- 
dents, by  machinery,  or  more  often  perhaps  they  have  been  caused 
by  a  fall  backwards  or  forwards,  when  the  anterior  extremity  of  the 
foot  was  wedged  under  some  solid  body  and  immovably  fixed. 
They  may  be  produced  also,  probably,  by  simply  striking  upon  the 
ball  of  the  foot  in  falling  from  a  height.  We  have  noticed,  however, 
that  Mr.  Smith  inclines  to  the  opinion  that  this  will,  in  general,  only 
produce  the  species  of  dislocation  which  he  has  particularly  described. 

The  symptoms  which  characterize  the  dislocation  of  the  whole 
range  of  metatarsal  bones  upwards  and  backwards  will,  when  the 
dislocation  is  complete,  resemble  very  much  those  which  belong  to 
the  dislocation  described  by  Smith.  The  dorsum  of  the  foot  will  be 
shortened  antero-posteriorly,  the  two  arches  of  the  foot  will  be  lost 
upon  the  plantar  surface,  or  even  actually  reversed,  a  ridge  will  tra- 
verse the  back  of  the  foot  and  a  corresponding  depression  will  exist 
underneath. 

In  some  cases,  however,  the  dislocation  is  not  complete,  the  articu- 
lations being  only  sprung,  and  then  there  can  exist  no  foreshortening 
of  the  foot,  and  all  the  other  signs  will  be  less  striking. 

If  only  a  single  bone  is  luxated  the  diagnosis  is  generally  very 

'  Dupuytren,  op.  cit.,  p.  326. 


DISLOCATIONS    OF    THE    METATAESAL    BONES.  709 

easily  made  out,  unless  indeed  considerable  swelling  has  already 
occurred. 

Mr.  South  says  that  in  1835,  a  case  was  admitted  to  St.  Thomas's 
Hospital,  under  Mr.  Green's  care,  of  dislocation  of  the  last  two  meta- 
tarsal bones,  occasioned  by  the  falling  of  a  heavy  chest  upon  the 
inside  of  the  foot.  Upon  the  top  of  the  foot  was  a  large  swelling 
below  and  in  front  of  the  outer  ankle,  and  behind  it  a  cavity  in  which 
two  fingers  could  be  easily  buried,  in  consequence  of  the  bases  of  the 
metatarsal  bones  having  been  thrown  upwards  and  backwards  upon 
the  top  of  the  cuboid  bone.  The  reduction  was  accomplished  with 
much  difficulty  by  continued  extension,  and  as  the  bones  resumed 
their  place  a  distinct  crackling  was  heard.^ 

Liston  reduced  a  dislocation  upwards  of  the  first  metatarsal  bone ; 
Malgaigne  mistook  a  dislocation  of  the  fourth  bone  for  a  fracture,  and 
did  not  attempt  the  reduction  until  the  seventh  day,  when,  after  five 
successive  trials,  the  head  entered  with  a  noise  into  its  cavity.  In  a 
dislocation  of  the  second,  third,  and  fourth  metatarsal  bones,  he  also 
failed  to  detect  the  true  nature  of  the  accident  until  the  tenth  day, 
when  he  proceeded  to  attempt  reduction,  but  failed.  Inflammation, 
suppuration,  and  delirium  followed,  and  the  patient  died  on  the  forty- 
first  day.  Tufnell  failed  in  a  similar  case,  although  his  patient  finally 
recovered  with  a  not  very  useful  limb.  Malgaigne  failed  to  reduce 
the  bones  also  in  a  recent  case  of  luxation  of  the  first  four  bones,  al- 
though he  used  chloroform,  and  diligently  tried  various  means.  The 
same  writer  has  seen  one  example  of  ancient  dislocation,  which  was 
not  recognized  by  the  surgeon.  Finally,  Monteggia  reports  a  case  of 
dislocation  of  the  last  two  metatarsal  bones,  which  was  not  at  the  time 
recognized.  Od  the  tenth  day  swelling  commenced,  and  soon  after  the 
patient  died  in  convulsions.^ 

These  references,  drawn  chiefly  from  Malgaigne,  sufficiently  illus- 
trate the  difficulty  which  surgeons  have  experienced  in  the  reduction 
of  these  bones,  when  a  portion  only  is  displaced.  A  difficulty  which 
is  probably  due  to  the  fact  that  it  is  almost  impossible  to  make  ex- 
tension upon  a  single  metatarsal  bone ;  indeed,  it  is  probable  that  by 
pressure  only  upon  the  displaced  head  can  we  expect  to  accomplish 
much  in  these  accidents,  and  even  this  cannot  be  made  to  act  very 
eflectively,  owing  to  the  small  amount  of  surface  presented  against 
which  the  force  can  be  properly  applied. 

If,  on  the  other  hand,  all  the  bones  are  dislocated  at  once,  the 
reduction  is  generally  accomplished  with  ease  by  simple  extension, 
combined  with  properly  directed  pressure.  Bouchard  and  Meynier 
succeeded  without  difficulty  in  two  cases  of  backward  dislocation ; 
Smyly  was  equally  successful  on  the  sixth  day,  in  a  case  of  disloca- 
tion downwards.  Laugier  reduced  an  outward  dislocation  of  all  the 
bones  by  pressure  and  extension  easily ;  and  Kirk  succeeded  as  well, 
in  an  example  of  the  opposite  character,  all  the  bones  being  carried 
inwards.' 

'  South,  Note  to  Chelius's  Surg.,  vol.  ii.  p.  256. 

2  Malgaigne,  op.  cit.,  p.  1077  et  seq.  '  Ibid.,  p.  lOSl. 


710       DISLOCATIONS    OF    THE    PHALANGES    OF    THE    TOES. 

Mr.  Sandwith  has  given  us  an  account  of  a  case  which  occurred  in 
his  own  person,  from  the  fall  of  his  horse  upon  his  foot.  "  I  was  in- 
stantly sensible,"  says  Mr.  Sandwith,  "of  the  nature  of  the  injury, 
and  as  soon  as  I  was  upon  my  feet,  the  metatarsus  was  found  to  be 
drawn  upwards,  and  obliquely  outwards  upon  the  tarsus,  by  the  action 
of  the  flexor  muscles.  On  the  removal  of  the  boot,  which  was  cut 
away,  these  were  the  appearances:  the  foot  considerably  shortened, 
the  toes  turned  a  little  outwards,  and  a  hard  swelling,  bigger  than  an 
egg,  upon  the  tarsus,  with  tumefaction  of  the  integuments.  The  pain, 
which  was  great  at  first,  was  kept  under  by  a  warm  fomentation. 

"The  reduction  was  easily  effected  by  my  friends,  Messrs.  Williams 
and  Brereton,  and  leeches  and  bread  and  water  poultices  prevented 
inflammation.  For  several  nights  the  foot  was  violently  shaken  by 
spasmodic  action  of  the  muscles,  but  the  parts  preserved  their  relative 
situation;  and,  although  it  was  nearly  a  year  before  all  lameness 
ceased,  yet  at  the  end  of  six  weeks  I  was  enabled  to  lay  aside  my 
crutches.  For  the  ability  to  use  the  foot  in  so  short  a  time,  I  was 
indebted  to  a  contrivance  which  rendered  the  foot  and  ankle  inflexible. 

"Instead  of  an  elastic  sole  to  the  shoe  part  of  the  apparatus,  one  of 
wood  was  procured,  around  the  heel  of  which  was  nailed  a  piece  of 
firm  unbending;  leather ;  this  reached  as  hiu;h  as  the  calf  of  the  leo- ; 
three  small  straps  with  buckles  held  the  leg  in  situ,  and  a  broader  one 
across  the  instep  secured  the  foot.  The  comfort  I  experienced  from 
this  simple  apparatus  is  my  reason  for  describing  it  so  particularly ;  it 
has  since  been  found  useful  in  various  injuries  of  the  foot  and  ankle."^ 

In  one  extraordinary  case,  however,  Dupuytren  was  not  so  success- 
ful. Paul  Eudes,  ast.  24,  fell,  while  drunk,  into  a  ditch  six  feet  deep, 
and  alighted  on  the  soles  of  his  feet.  This  accident  was  followed  by 
great  swelling,  and  he  did  not  suspect  the  nature  of  the  injury,  or 
present  himself  at  the  hospital  until  three  weeks  after.  Dupuytren 
then  ascertained  that  he  had  dislocated  the  metatarsal  bones  of  both 
feet.  Several  fruitless  attempts  were  made  to  accomplish  the  reduc- 
tion, but  to  no  purpose,  and  in  about  two  weeks  he  left  the  hospital.^ 


CHAPTER   XXIV. 

DISLOCATIONS   OF  THE  PHALANGES   OP  THE  TOES. 

Dislocations  of  the  toes  are  less  common  than  those  of  the  fingers, 
yet  a  considerable  number  of  cases  have  been  recorded  by  different 
surgeons.     They  are  occasioned  by  blows  received  directly  upon  the 

'  Sandwith,  Amer.  Journ.  Med.  Sci.,  Nov.  1828,  p.  216,  from  Lond.  Med.  Gaz., 
vol.  i.  '^  Dupujtren,  op.  cit.,  p.  329. 


DISLOCATIONS    OF    THE    PHALANGES    OF    THE    TOES.       711 

ends  of  the  toes,  by  the  weight  of  the  body  brought  to  bear  suddenly 
upon  their  plantar  surfaces,  as  when  a  horseman  springs  in  his  stirrup, 
or  by  a  fall,  in  consequence  of  which  the  rider  hangs  in  his  stirrup, 
by  leaping,  &c. 

They  may  be  partial  or  complete ;  and  in  the  latter  case,  a  slight 
overlapping  is  generally  observed.  In  a  great  majority  of  cases  the 
direction  of  the  displacement  is  backwards,  or  with  only  a  slight  lateral 
deviation.  Occasionally,  several  bones  are  displaced  at  the  same  time, 
but  usually  only  one  suffers  displacement.  It  is  more  common  here 
to  find  compound  and  complicated  dislocations  than  in  the  case  of  the 
fingers. 

The  position  of  the  toes  is  not  always  the  same  in  the  same  form  of 
dislocations.  Thus,  in  the  dislocation  backwards,  the  toe  is  sometimes 
reversed  upon  the  foot  to  nearly  a  right  angle,  and  at  other  times  it  is 
found  lying  in  the  same  axis  as  the  metatarsal  bone,  or  the  phalanx, 
from  which  it  is  luxated.  About  oneyear  since,  I  reduced  a  backward 
dislocation  of  the  first  phalanx  of  the  second  toe  in  the  person  of  Lewis 
Brittin,  set.  60,  who  had  fallen  from  a  four  story  window,  striking  upon 
his  feet,  and  breaking  both  thighs.  I  did  not  discover  the  dislocation 
of  the  toe  until  sixteen  hours  after  the  accident.  It  was  then  lying 
parallel  with  the  axis  of  the  metatarsal  bone,  upon  which  it  was  slightly 
overlapped.  The  reduction  was  effected  easily  by  pulling  upon  the 
last  phalanx  with  my  fingers,  while,  at  the  same  moment,  I  pushed 
the  head  of  the  bone  toward  the  socket.  No  swelling  followed,  nor 
has  it  troubled  him  at  all  since  his  recovery. 

With  regard  to  the  treatment,  surgeons  have  experienced  the  same 
difficulty  in  certain  cases  of  dislocation  of  the  great  toe  as  we  have 
seen  experienced  in  similar  dislocations  of  the  thumb.  Occasionally, 
indeed,  the  reduction  has  been  found  to  be  impossible.  The  same 
doubts  have  existed  also  in  relation  to  the  causes  of  this  difficulty,  and 
in  reference  to  the  means  by  which  it  was  to  be  overcome.  We  shall 
therefore  refer  the  reader  to  the  chapter  on  Dislocations  of  the  First 
Phalanges  of  the  Thumb  and  Fingers  for  a  more  full  consideration  of 
this  matter. 

In  case  the  smaller  toes  are  luxated,  the  reduction  is  generally 
effected  with  ease,  by  simple  extension,  or  by  extension  combined  with 
pressure;  sometimes,  also,  the  bone  will  be  more  easily  put  in  place 
by  reversing  the  phalanx  more  completely,  as  we  have  advised  in  cer- 
tain cases  of  dislocation  of  the  fingers. 

If  the  skin  is  penetrated,  it  will  often  be  found  necessary  either  to 
amputate  or  to  practice  resection  upon  the  exposed  phalanx. 

Sir  Astley  Cooper  relates  a  case  of  luxation  of  "all  the  smaller 
toes,"  from  the  metatarsus,  which  had  not  been  reduced,  and  the  sub- 
ject of  which  was,  in  consequence,  so  much  maimed  that  he  was  unable 
to  labor.  It  had  been  occasioned  by  a  fall,  from  a  considerable  height, 
upon  the  extremities  of  the  toes.  A  projection  existed  at  the  roots  of 
all  the  smaller  toes,  the  extremity  of  each  metatarsal  bone  being  placed 
under  the  first  phalanx  of  its  corresponding  toe.  The  swelling,  which 
immediately  followed  the  receipt  of  the  injury,  had  concealed  its 
nature,  and  now,  several  months  having  elapsed,  reduction  could  not 


712         COMPOUND    DISLOCATION'S    OF    THE   LONG   BONES. 

be  effected.  The  only  relief  which  could  be  afforded  him,  therefore, 
was  in  wearing  a  piece  of  hollow  cork  at  the  bottom  of  the  inner  part 
of  the  shoe,  to  prevent  the  pressure  of  the  metatarsal  bones  upon  the 
nerves  and  bloodvessels.* 


CHAPTER    XXV. 

COMPOUND   DISLOCATIONS   OF  THE  LONG  BONES. 

Frequencij  of  Com'pound  as  compared  with  Simple  Dislocations. — Com- 
pound dislocations,  as  compared  with  simple,  are  of  rare  occurrence. 
Of  ninety-four  dislocations  reported  by  Norris  as  having  been  re- 
ceived into  the  Pennsylvania  Hospital  for  the  ten  years  ending  in 
1840,  only  two  were  compound;^  and  of  one  hundred  and  sixty-six 
dislocations  recorded  in  my  observations,  only  eight  were  compound.^ 

Relative  Frequency  in  the  Different  Joints. — In  my  own  recorded  cases, 
four  were  dislocations  of  the  tibia  inwards  at  the  ankle-joint,  one  was 
a  partial  (pathological)  luxation  forwards  at  the  same  joint,  one  was  a 
luxation  of  the  astragalus,  one  a  luxation  of  the  head  of  the  humerus 
into  the  axilla,  and  one  a  forward  luxation  of  the  radius  and  ulna  at 
the  wrist-joint.  Both  of  the  cases  reported  by  Norris  were  disloca- 
tions of  the  thumb. 

Sir  Astley  Cooper,  speaking  upon  this  point,  says  that  the  elbow, 
wrist,  ankle,  and  finger-joints  are  most  subject  to  these  accidents;  and 
that  he  has  seen  but  two  in  the  shoulder-joint,  and  one  in  the  knee- 
joint.  He  had  never  seen  a  compound  dislocation  at  the  hip-joint,  and 
he  believed  that  it  was  "  scarcely  ever"  so  dislocated.  Mr.  Bransby 
Cooper  has,  however,  reported  in  detail  a  very  interesting  case  of  this 
accident,  communicated  to  him  by  Dr.  Walker,  of  Charlestown,  Mass., 
in  which  reduction  was  accomplished  by  manipulation  alone,  by  Dr. 
Ingalls,  on  the  second  day.  The  patient  died  at  the  end  of  about  three 
weeks."*  So  far  as  I  know,  this  is  the  only  case  upon  record.  Mal- 
gaigne  says  that  a  compound  dislocation  at  the  hip-joint  has  probably 
never  occurred. 

Among  the  cases  of  compound  dislocation  recorded  by  Sir  Astley 
and  Bransby  Cooper,  most  of  which  were  communicated  to  these  gen- 
tlemen by  other  surgeons,  45  were  dislocations  of  the  ankle,  10  of  the 
astragalus,  4  of  the  ulna  at  the  wrist-joint,  4  of  the  thumb,  2  of  the 

'  Sir  Ast.  Cooper,  op.  cit.,  p.  385. 

^  Norris,  Amer.  Journ.  Med.  Sci.,  April,  1841,  p.  335. 

*  For  the  most  of  these  cases,  see  Transactions  of  the  New  York  State  Med.  Soc. 
for  1855  ;  article  entitled  "  Report  on  Dislocations,  with  especial  reference  to  their 
Results."     By  F.  H.  Hamilton. 

*  A.  Cooper,  on  Dislocations,  &c.,  by  B.  Cooper,  p.  59. 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.         713 

knee,  1  of  the  shoulder,  1  of  the  elbow,  1  of  the  radius  and  ulna  at 
the  wrist,  1  of  the  scaphoid  bone,  and  1  of  the  metatarsal  bone  of  the 
great  toe.  Other  writers  have  occasionally  described  compound  dislo- 
cations of  the  clavicle,  but  I  know  of  no  record  of  a  compound  dislo- 
cation of  the  lower  jaw. 

Prognosis^  as  chtermined  ly  the  Mode  of  Treatment  adopted  ly  most  of 
the  Ancient  and  many  of  the  Modern  Surgeons. — By  most  of  the  early 
writers  these  accidents,  whenever  they  occurred  in  the  larger  joints, 
were  regarded  as  nearly  beyond  the  reach  of  art.  Says  Hippocrates : 
"  In  cases  of  complete  dislocation  at  the  ankle-joint,  complicated  with 
an  external  wound,  whether  the  displacement  be  inwards  or  outwards, 
you  are  not  to  reduce  the  parts,  but  let  any  other  physician  reduce 
them  if  he  choose.  For  this  you  should  know  for  certain,  that  the 
patient  will  die  if  the  parts  are  allowed  to  remain  reduced,  and  that 
he  will  not  survive  more  than  a  few  days,  for  few  of  them  pass  the 
seventh  day,  being  cut  off  by  convulsions,  and  sometimes  the  leg  and 
foot ■  are  seized  with  gangrene."  Hippocrates  adds:  "But  if  not  re- 
duced, nor  any  attempts  at  first  made  to  reduce  them,  most  of  such 
cases  recover."^ 

The  same  remarks  are  applied  by  Hippocrates  to  compound  dislo- 
cations of  the  head  of  the  tibia,  of  the  lower  end  of  the  femur,  of  the 
wrist,  elbow,  and  shoulder-joints ;  death  occurring  in  all  cases,  as  he 
believes,  more  or  less  speedily  whenever  the  bones  are  reduced  and 
retained  in  place  a  suflQcient  length  of  time,  and  "  Avere  it  not  that  the 
physician  would  be  exposed  to  censure,"  he  would  not  reduce  even 
the  bones  of  the  fingers,  since  it  must  be  expected,  he  thinks,  that 
their  articular  extremities  will  exfoliate  even  when  the  reduction  is 
most  successful. 

I  shall  presently  show,  however,  that  even  Hippocrates  advised  and 
probably  practiced  resection  in  certain  cases  of  these  accidents. 

Both  Celsus  and  Galen  adopt  almost  without  qualification  the  line 
of  practice  laid  down  by  Hippocrates,  and  affirm  equally  the  danger  and 
almost  certain  death,  consequent  upon  the  reduction  of  compound  dis- 
locations in  large  joints.^    Celsus  recommends  resection  in  some  cases. 

Paulus  /Figineta,  however,  and  after  him  Albucasis,  Haly  Abbas, 
and  Ehazes,  do  not  regard  the  rules  established  by  Hippocrates,  in 
relation  to  the  non-reduction  of  the  bones,  as  so  imperative,  nor  the 
results  of  the  opposite  practice  as  so  uniformly  fatal. 

"  Hippocrates  remarks,"  says  Paulus  Jl^gineta,  "  in  the  case  of  dis- 
locations with  a  wound,  the  utmost  discretion  is  required.  For  these, 
if  reduced,  occasion  the  most  imminent  danger,  and  sometimes  death, 
the  surrounding  nerves  and  muscles  being  inflamed  by  the  extension, 
so  that  strong  pains,  spasms,  and  acute  fevers,  are  produced  more  par- 
ticularly in  the  case  of  the  elbows,  knees,  and  joints  above,  for  the 
nearer  they  are  to  the  vital  parts  the  greater  is  the  danger  they  induce. 
Wherefore,  Hippocrates,  by  all  means,  forbids  us  to  apply  reduction 
and  strong  bandaging  to  them,  and  directs  us  to  use  only  anti-inflam- 

1  Works  of  Hippocrates,  Sydenham  ed.,  LoBdon,  vol.  ii.  p.  634. 

2  Paulus  ^gineta,  Syd.  ed.,  vol.  ii.  p.  510. 


714         COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

matorj  and  soothing  applications  to  them  at  the  commencement,  for 
that  by  this  treatment  life  may  sometimes  be  preserved.  But  what 
he  recommends  for  the  fingers  alone,  we  would  attempt  to  do  for  all 
the  other  joints ;  at  first,  and  while  the  parts  remain  free  from  inflam- 
mation, we  would  reduce  the  dislocated  joint  by  moderate  extension, 
and  if  we  succeed  in  our  object,  we  may  persist  in  using  the  anti-in- 
flammatory treatment  only.  But  if  inflammation,  spasm,  or  any  of 
the  afore-mentioned  symptoms  come  on,  we  must  dislocate  it  again  if 
it  can  be  done  without  violence.  If,  however,  we  are  apprehensive 
of  this  danger  (for  perhaps  if  inflammation  should  come  on  it  will 
not  yield),  it  will  be  better  to  defer  the  reduction  of  the  greater  joints 
at  the  commencement;  and  when  the  inflammation  subsides,  which 
happens  about  the  seventh  or  ninth  day,  then,  having  foretold  the 
danger  from  reduction,  and  explained  how,  if  not  reduced,  they  will 
be  mutilated  for  life,  we  may  try  to  make  the  attempt  without  violence, 
using  also  the  lever  to  facilitate  the  process."^ 

In  the  following  quotations  from  three  of  the  most  celebrated 
writers  of  the  last  two  centuries,  we  find  but  little,  if  any  evidence 
that  the  opinions  of  the  fathers  upon  this  subject  were  not  still  held 
in  general  respect:  "If  the  joint  be  dislocated,  so  that  it  is  either 
uncovered,  or  a  little  thrust  forth  without  the  skin,  the  accident  is 
mortal,  and  of  more  danger  to  be  reduced  than  if  it  be  not  reduced. 
For  if  it  be  not  reduced,  inflammation  will  come  upon  it,  convulsion, 
and  spmetimes  death.  2.  There  will  be  a  filthiness  of  the  part  itself. 
3,  An  incurable  ulcer,  and  if  perhaps  it  be  brought  to  cicatrize  at  all, 
it  will  easily  be  dissolved  by  reason  of  the  softness  of  it :  but  if  it  be 
reduced,  it  brings  extreme  danger  of  convulsion,  gangrene,  and 
death."^ 

"Si  vero  in  magnis  articulis  tam  valida  fuit  facta  luxatio,  ut  liga- 
mentis  ruptis  os  articuli  multum  sit  protrusum  per  integumenta,  hsec 
pars  ossis  vasis  privata  moritur,  citius  autem  si  reponatur,  quam  si 
non  reponitur;  quare  sola  amputatio  restat  ad  conservationem  vit^."^ 

Heister,  who  makes  no  allusion  to  this  subject  in  the  first  edition 
of  his  great  work,  published  at  Amsterdam  in  1739,  adds  the  following 
remarks  in  his  last  edition,  translated  and  published  in  London  in 
1768:  "Dislocations  attended  with  a  wound,  especially  of  the  shoulder 
or  thigh-bone,  are  of  very  bad  consequence,  and  often  endanger  the 
life  of  the  patient;  in  Celsus's  opinion  (Book  VIII.  Chap.  XXY.), 
whether  the  bones  be  replaced  or  not,  there  is  generally  great  danger ; 
and  so  much  the  more  the  nearer  the  wound  is  to  the  joint.  Hippo- 
crates has  declared  that  no  bones  can  be  reduced  with  security,  beside 
those  of  the  hands  and  feet.  ( Vectiar.  19,  5.)  See  more  on  this  subject 
in  that  passage  of  Celsus  just  now  quoted,  though  I  by  no  means 
recommend  the  following  him  implicitly.""* 

'  Paulus  iEgineta,  Syd.  ed.,  voL  ii.  p.  509. 

^  "Chirurgeon's  Storehouse."  By  Johannes  Scultetus,  of  Ulme,  in  Suevia.  London 
ed.,  1674,  p.  31. 

^  Johannes  de  Gorter.     Chirurgia  repurgata.     Lngdnni  Batavoreni,  1742,  t.  86. 

*  General  System  of  Surgery,  by  Dr.  Laurence  Heister.  8th  ed.  London,  1768. 
VoL  i.  p.  164. 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.         715 

Sucli  were  the  extreme  views  as  to  the  fatality  of  these  accidents, 
and  of  the  feebleness  of  our  resources  entertained  by  the  ancient,  and 
even  by  the  more  modern  writers  almost  down  to  our  own  day;  with 
only  rare  exceptions  these  limbs  were  condemned  either  to  great  and 
inevitable  deformity,  or  to  amputation.  Nor,  if  we  speak  only  of 
their  fatality,  have  surgeons  ceased  to  regard  these  accidents  as  among 
the  most  grave  with  which  they  have  to  deal. 

Pathology,  and  Ajjpreciaiion  of  the  Sources  of  Danger  as  compared  es- 
pecially loith  Compound  Fractures. — The  danger,  according  to  Sir 
Astley  Cooper,  consists  in  the  rapid  inflammation  of  the  synovial 
membranes,  which  is  speedily  followed  by  suppuration  and  ulceration, 
whereby  the  ends  of  the  bones  become  exposed ;  and  for  the  repair  of 
which  lesions,  great  general  as  well  as  local  eflbrts  are  required,  and 
a  high  degree  of  constitutional  irritation  results.  In  addition  to  which 
circumstances,  "the  violence  inflicted  on  the  neighboring  parts,  the 
injury  of  the  muscles  and  tendons,  and  the  laceration  of  bloodvessels, 
necessarily  lead  to  more  important  and  dangerous  consequences  than 
those  which  follow  simple  dislocations." 

The  sources  of  danger  enumerated  by  Sir  Astley  Cooper  have  been 
regarded  as  sufficient  to  account  for  their  extraordinary  fatality  by 
the  majority  of  those  modern  surgical  writers  who  have  alluded  to  the 
subject;  but  I  must  confess  that  to  me  they  do  not  appear  so.  In 
compound  fractures  the  mortality  is  far  less ;  yet  one  might  naturally 
suppose,  that  when  the  sharp  and  irregular  fragments  are  pressing 
into  the  flesh,  among  nerves  and  bloodvessels,  the  irritation  and  in- 
flammation would  be  equal,  if  not  more  than  equal  to  the  irrita- 
tion and  consequent  inflammation  produced  by  exposing  a  joint 
surface  to  the  air;  indeed,  modern  experience  has  sufficiently  shown 
that  these  surfaces  are  much  more  tolerant  of  atmospheric  exposure, 
and  of  the  action  of  many  other  irritants,  than  surgeons  formerly  sup- 
posed. A  clean  incision  into  a  large  joint,  which  exposes  the  synovial 
membranes  to  the  air,  and  which  permits  the  products  of  inflammation 
to  escape  freely,  is  attended  with  much  less  danger  than  a  small  punc- 
ture which  does  not  at  all  permit  the  air  to  enter,  nor  the  increased 
synovia  and  the  pus  to  escape.  Very  grave  results  sometimes  follow 
from  large  wounds  into  large  joints,  but  under  judicious  treatment 
such  results  are  the  exception  and  not  the  rule.'  But  Sir  Astley 
evidently  attributes  more  of  the  bad  consequences  to  the  exhausting 
effects  of  the  eftbrts  at  repair,  than  to  the  immediate  inflammation 
resulting  from  the  exposure  of  the  joint.  It  is  pretty  certain,  how- 
ever, that  a  majointy  of  these  patients  die  at  a  period  too  early  to  ren- 
der this  cause  in  any  considerable  degree  operative. 

As  to  the  bruising  of  the  "  muscles  and  tendons,  and  laceration  of 
bloodvessels,"  it  cannot  be  denied  that  it  must  usually  be  greater  than 
in  "simple  dislocations ;"  and  I  will  not  say  that  it  is  not  in  a  given 
number  of  instances  greater  than  in  the  same  number  of  instances  of 

1  Upon  this  point  see  tlie  very  able  article  entitled  "  Amputations  and  Compound 
Fractures,"  by  John  0.  Stone,  in  the  New  York  Journal  of  Medicine,  vol.  iii.  of  2d 
series,  p.  316,  Nov.  1849. 


716         COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

compound  fractures.  The  tissues  have  often  been  thrust  rudely  through 
by  a  large  and  smooth  bone,  and  the  tendons  have  been  stretched 
violently  or  torn  completely  asunder;  while  occasionally  large  arte- 
ries, which  are  prone  to  hug  the  bones  about  the  joints,  are  lacerated 
and  left  to  bleed.  That  the  importance  of  these  complications,  how- 
ever, may  not  be  over-estimated,  we  must  state  that  Sir  Astley  Cooper 
himself  has  remarked  how  seldom,  in  compound  dislocations  of  the 
ankle-joint,  the  large  arteries  are  injured ;  that  a  tearing  of  the  liga- 
ments and  of  the  tendons  is  almost  as  likely  to  occur  in  simple  disloca- 
tions as  in  compound ;  and,  indeed,  that  in  neither  case  are  the  tendons 
usually  ruptured,  but  only  thrust  aside.  Moreover,  the  skin  is  often 
made  to  give  way  not  so  much  from  the  pressure  of  the  round  head 
within,  as  from  the  equal  pressure  of  some  sharp  angular  body  from 
without.  In  all  these  respects,  there  are  many  examples  of  compound 
fractures  which  possess  not  a  whit  of  advantage;  in  which  cases, 
nevertheless  the  surgeon  feels  very  little  doubt  as  to  the  ultimate  cure. 

In  short,  the  causes  which,  according  to  Sir  Astley  Cooper,  deter- 
mine the  extraordinary  fatality  of  these  accidents,  do  not  sufficiently 
differ  from  those  which  operate  in  compound  fractures  to  occasion 
so  great  a  difference  in  results,  and  the  fatality  of  compound  disloca- 
tions remains  unexplained  ;  or  if  surgical  writers  have  here  and  there 
intimated  the  true  cause,  they  have  failed  to  give  it  its  proper  place 
and  value. 

I 'think  the  cause  of  the  greater  fatality  of  compound  dislocations 
over  compound  fractures  is  to  be  found  in  the  simple  fact  that  dis- 
locations are  generally  reduced,  and  by  splints  or  other  apparatus 
successfully  maintained  in  place,  while  compound  fractures,  as  my 
statistical  report  of  cases  has  proven,  are  not  generally  reduced  com- 
pletely, nor  can  they  by  any  means  yet  devised,  except  in  a  few  cases, 
be  maintained  in  place  if  reduced.  Broken  limbs,  whether  simple  or 
compound  in  their  character,  will  in  a  great  majority  of  cases  shorten 
upon  themselves  in  spite  of  the  most  assiduous  and  skilful  attempts 
to  prevent  it.^ 

In  adults  most  bones  break  obliquely,  and  cannot  be  made  to  sup- 
port each  other,  and  even  in  transvei'se  fractures  the  broken  ends  are 
generally  small  compared  with  the  articular  ends  of  the  same  bones, 
and  afford  a  very  uncertain  and  inadequate  support  for  themselves; 
not  to  speak  of  the  difficulty  of  once  bringing  their  ends  into  exact 
apposition  where  the  muscles  are  powerful,  or  where  they  lie  embedded 
in  a  large  mass  of  flesh  so  that  they  cannot  be  felt.  While,  on  the 
other  hand,  dislocated  bones,  whether  simple  or  compound,  are  capable 
when  restored  to  place  of  supporting  themselves;  or  with  only  slight 
assistance,  their  reduction  may  be  maintained ;  it  is  also  ordinarily  a 
work  of  no  great  difficulty  to  reduce  them. 

Herein,  then,  consists  the  most  important  difference  between  these 
two  classes  of  accidents,  which  are  in  other  respects  so  similar.  In 
the  one,  the  very  nature  of  the  injury  prevents  the  complete  reduc- 

'  "Report  on  Deformities  after  Fractures."  Trans.  Am.  Med.  Assoc,  vol.  viii.  ix. 
and  X. 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.         717 

tion,  and  the  consequent  violent  strain  of  the  muscles,  tendons,  and 
other  soft  tissues ;  while  in  the  other,  the  nature  of  the  accident  leaves 
it  in  the  power  of  the  surgeon  to  reduce  the  bones,  and  modern  sur- 
gery has  in  a  great  measure  sanctioned  the  practice  of  maintaining 
them  in  place,  in  defiance  of  the  efforts  of  the  muscles,  and  sometimes, 
no  doubt,  at  the  imminent  hazard  of  the  life  of  the  patient. 

Is  it  not  fair  to  presume  that  tissues  which  have  been  stretched  and 
lacerated,  require  rest  in  order  that  they  may  recover  from  the  effects 
of  their  injuries?  And  if  the  soft  parts  are  really  more  injured  in 
dislocations  than  in  fractures,  does  not  the  indication  for  rest  become, 
for  this  very  reason,  more  imperative  ? 

General  Inferences. — We  have  come,  then,  to  regard  the  shortening 
of  limbs  after  fractures,  within  certain  limits  and  in  certain  cases,  as  a 
conservative  circumstance  rather  than  as  a  circumstance  which  the 
surgeon  should  in  all  cases  seek  to  prevent. 

There  is  abundant  evidence  that  the  ancients  had  some  knowledge 
of  the  value  of  rest  to  the  muscles,  tendons,  &g.,  in  the  prevention  of 
inflammation  after  compound  dislocations,  since  they  constantly  urge 
the  greater  danger  of  reducing  these  dislocations,  than  of  leaving  them 
unreduced  ;  and  they  do  not  hesitate  to  recommend,  that  in  case  vio- 
lent inflammation  supervenes  upon  the  reduction,  the  bone  shall  im- 
mediately be  again  dislocated.  Galen  speaks  very  explicitly  on  this 
subject,  and  says  that  "the  danger  in  reduction  consists  partly  in  the 
additional  violence  inflicted  on  the  muscles,  and  partly  in  their  being 
then  put  into  a  stretched  state,  whereby  spasms  or  convulsions  are 
brought  on,  and  gangrene  as  the  result  of  the  intense  inflammation 
which  ensues;"  and  Paulus  ^gineta  remarks:  "For  these,  if  reduced, 
occasion  the  most  imminent  danger,  and  sometimes  death;  the  sur- 
rounding nerves  and  muscles  being  inflamed  by  the  extension,"  &c. 

I  have  already  quoted  from  Sir  Astley  Cooper  the  causes  or  rea- 
sons which  he  has  assigned  for  the  fatality  of  compound  dislocations ; 
and  the  same  reasons  have  generally  been  assigned  by  those  who  have 
written  since  his  day  ;  but  he  has"  elsewhere,  when  speaking  of  ex- 
section,  given  place  to  the  very  idea  for  which  we  claim  so  much  pro- 
minence, the  danger  arising  from  a  stretching  of  the  muscles.  Mr. 
Listen,  also,  and  Mr.  Miller,  when  speaking  especially  of  dislocations 
of  the  tibia  at  the  ankle-joint,  refer  to  the  same  source  of  danger. 

Treatment.— LQi  us  see  now  the  alternatives  which  surgery  presents 
for  the  treatment  of  these  intractable  accidents. 

1.  Eeduction  of  the  bone. 

2.  Non-reduction. 

3.  Amputation. 

4.  Tenotomy. 

5.  Besection  and  reduction. 

The  questions  for  us  to  consider  are,  first,  by  which  of  these  several 
methods  is  the  life  of  the  patient  rendered  most  secure  ?  and  second, 
where  of  two  or  more  methods  all  are  equally  safe,  by  which  will  he 
suffer  the  least  maiming  or  mutilation? 

By  Eeduction.— Wehsive  seen  already  how  the  old  surgeons  regarded 
the  practice  of  reducing  compound  dislocations  of  the  larger  joints. 


718         COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

It  is  not  difficult,  however,  to  find  in  the  records  of  surgery  numerous 
examples  of  successful  terminations  under  this  practice. 

Dr.  White,  of  Hudson,  N.  Y.,  has  reported  a  case  of  this  kind  in 
which  the  dislocation  was  at  the  ankle-joint.^  Pott  says  he  has  seen 
this  practice  occasionally  succeed,^  and  Mr.  Scott  communicated  to 
the  Lancet  in  March,  1837,  a  case  of  compound  dislocation  of  the 
humerus  successfully  treated  by  reduction.  Sir  Astley  Cooper  also 
records  several  cases  of  compound  dislocations  at  the  lower  end  of  the 
tibia  and  fibula,  successfully  treated  by  reduction. 

A  careful  examination,  however,  of  those  cases  reported  by  Sir 
Astley  as  having  been  reduced  without  resection,  and  which  resulted 
in  cures,  does  not,  in  my  opinion,  leave  much  substantial  evidence  in 
favor  of  the  practice ;  or  perhaps  we  ought  rather  to  say  that  it  leaves 
only  a  qualified  evidence  of  its  propriety  in  certain  cases.  He  has 
mentioned  about  sixteen  of  these  examples,  comprising  dislocations  of 
the  lower  end  of  the  tibia,  or  of  the  tibia  and  fibula,  outwards,  also 
inwards  and  forwards,  all  of  which,  save  one  quoted  from  Mr.  Liston, 
have  been  reported  to  him  by  other  surgeons,  and  not  one  of  which 
had  he  ever  seen  himself  Many  of  the  cases  are  reported  very  loosely, 
evidently  in  reply  to  circular  letters,  and  from  memory,  without  re- 
corded notes,  and  by  unknown,  and  in  some  sense  irresponsible  sur- 
geons. It  is  not  always  said  whether  the  wounds  in  the  soft  parts 
were  made  by  the  protrusion  of  the  bones,  or  by  some  external 
violence;  yet  this  is  certainly  a  very  material  point  in  determining 
whether  reduction  is  to  be  followed  by  inflammation  or  not.  The 
results,  sometimes  only  attained  after  exposure  to  great  hazards,  are, 
after  all,  often  sufficiently  unfavorable. 

It  will  be  noticed,  also,  that  in  Cases  152  and  153,  the  astragalus 
was  comminuted  and  removed,  either  at  first  or  at  a  later  day;  and 
in  Cases  154,  155,  156,  and  160,  the  tibia,  and  also  probably  the 
fibula,  was  broken,  and  it  does  not  appear  but  that  in  consequence  of 
this  complication  the  limb  became  shortened,  and  the  muscles  were 
thus  put  at  rest,  very  much  as  if  the  bones  had  been  retracted ;  and 
in  one  of  the  cases  enumerated  under  161,  the  lower  end  of  the  tibia 
spontaneously  exfoliated.  That  a  comminution,  or  that  any  fracture 
of  the  astragalus  or  of  the  tibia  and  fibula,  should  be  regarded  in  these 
cases  as  rendering  the  accident  less  grave,  can  only  be  comprehended 
by  a  full  appreciation  of  the  value  of  relaxation  of  the  muscles. 

The  few  cases  which  remain  after  this  exclusion  do  indeed  illustrate 
how  nature  and  skill  may  triumph  over  great  difficulties,  but  nothing- 
more. 

It  is  possible,  also,  that  some  of  these  examples  of  recovery  after 
reduction  may  admit  of  an  explanation  entirely  consistent  with  our 
own  views  of  the  true  source  of  the  danger  in  these  accidents,  if  indeed 
they  do  not  tend  actually  to  confirm  our  doctrines.  I  have  myself 
seen  one  example  of  complete  recovery  after  the  reduction  of  a 
compound   dislocation    at    the   anlile-joint,    although   resection   was 

'  White,  Amer.  Journ.  Med.  Sci.,  Nov.  1828,  p.  109. 
2  Pott,  Chirurg.  Works,  voL  ii.  p.  243. 


^,  COMPOUND    DISLOCATIONS    OF    THE    LONG    BONE«.         719 

not  practiced ;  but  in  this  case,  all  tlie  tissues,  or  nearly  all  which 
suffered  any  iujur}^,  were  completel}^  torn  asunder,  and  therefore 
wholly  removed  from  the  danger  of  which  we  have  spoken.  The 
example  to  which  we  allude  is  the  following:  On  the  30th  of  Oct., 
1858,  John  Bourquard,  set.  30,  was  caught  in  the  tow-line  of  a  canal 
boat,  causing  a  compound  dislocation  of  the  right  ankle-joint.  I  found 
the  foot,  immediately  after  the  accident,  thrown  completely  back 
against  the  lower  part  of  the  leg,  the  integuments  in  front  of  the  joint, 
as  well  as  all  of  the  tendons  and  ligaments  on  this  side,  being  com- 
pletely torn  asunder,  while  the  tendo-Achillis,  and  the  tendons  behind 
both  of  the  malleoli,  with  the  corresponding  integuments,  were  unin- 
jured. This  immunity  of  the  tissues  behind  the  malleoli  was  due  to 
the  direction  in  which  the  foot  w^as  drawn,  namely,  directly  back- 
wards. Everything  which  had  suffered  a  strain  being  thoroughly 
severed,  I  did  not  hesitate  to  attempt  to  save  the  limb  without  re- 
section. The  reduction  was  accomplished  very  easily.  The  leg  and 
foot  were  placed  in  a  box  filled  with  bran,  and  cool  water  dressings 
were  applied  to  the  portion  which  was  exposed.  On  the  22d  of 
November,  the  limb  was  removed  from  the  bran  to  a  pillow,  the 
union  being  sufficient  not  to  demand  so  much  lateral  support.  About 
the  first  of  March  he  left  the  hospital,  the  wound  having  closed,  but 
the  ankle  remaining  swollen  and  stiff". 

I  have  also  during  the  last  year  seen  two  cases  in  which  the  foot 
has  been  nearly  severed  from  the  leg  through  the  ankle-joint,  by  means 
of  a  "  reaper."  In  each  case  the  patient  was  standing  with  his  back 
to  the  machine,  and  one  of  the  blades  cut  horizontally  from  side  to  side, 
severino-  everything  except  about  three  inches  of  integument  in  front, 
and  the°extensor  tendons  of  the  toes.  In  the  first  instance,  having  seen 
the  patient,  a  gentleman  nearly  sixty  years  of  age,  within  three  or 
four  hours  of  the  time  of  the  receipt  of  the  injury,  I  found  him  ex-_ 
ceedingly  exhausted  by  the  hemorrhage.  Both  malleoli  were  cut  oft' 
smoothly,  the  knife  having  severed  the  limb  so  exactly  through  the 
joint,  as  to  have  touched  the  cartilage  at  but  one  or  two  points.  Havmg 
secured  the  bloodvessels.  I  replaced  the  foot,  and  after  a  few  days  of 
attendance  I  left  him  in  the  charge  of  an  excellant  young  surgeon, 
Br.  Robertson,  of  Lancaster,  N.  Y.,  to  whose  diligence  and  skill  the 
patient  is  no  doubt  mainly  indebted  for  his  recovery.  After  the  lapse 
of  nearly  one  year  he  is  able,  by  the  assistance  of  a  shoe  furnished 
with  lateral  supports,  to  walk  very  well  In  the  second  case,  which 
was  onlv  brouoht  to  my  notice  some  months  after  the  accident  occurred, 
in  consequen(?e  of  a  troublesome  fistula  near  the  ankle-joint,  the  re- 
covery had  been  complete  except  that  a  small  fragment  of  one  ot  the 
malleoli  was  necrosed  and  required  removal. 

Br  Eli  Kurd,  of  Niagara  Co.,  N.  Y.,  was  equally  fortunate  m  a  case 
of  compound  dislocation  of  the  shoulder-joint.  This  was  m  the  person 
of  a  T  ffit  30,  who  was  caught  in  the  gearing  of  a  thrashmg  machine 
on  the  isth  of  Feb.  1852,  which  having  drawn  him  m  with  great  force 
dislocated  the  head  of  the  left  humerus  downwards  through  the  integu- 
ments into  the  axilla.  Reduction  was  accomplished  according  to  the 
method  recommended  by  Nathan  Smith,  by  pulling  from  each  wrist 


720         COMPOUND   DISLOCATIONS    OF    THE    LONG    BONES. 

at  right  angles  with  the  bodj,  while  the  operator  himself  seized  the 
naked  head  of  the  humerus  with  his  left  hand,  his  right  resting  upon 
the  top  of  the  shoulder,  and  pushed  it  into  place.  The  time  occupied 
in  the  reduction  was  about  thirty  seconds.  The  forearm  was  then 
suspended  in  a  sling,  and  the  venous  hemorrhage,  occasioned  by  a 
rupture  of  the  subclavian  vein,  was  arrested  by  compression.  The 
tegumentary  wound,  between  three  and  four  inches  in  length,  was 
subsequently  closed  by  sutures  and  cool  water-dressings  were  applied. 
On  the  fourth  day  the  wound  had  united  by  first  intention,  and  the 
man  was  walking  about  his  room.  In  less  than  a  month  he  was  dis- 
missed cured,  and  in  the  following  harvest  he  was  able  to  cut  his  own 
hay  and  grain,  and  to  use  his  arm  as  before  the  accident.^ 

Miller  and  Hoffman  reduced  successfully  a  compound  dislocation 
of  the  knee,^  and  Galli  has  communicated  a  similar  case  to  Malgaigne.^ 

Whether  either  of  the  three  last  mentioned  examples  admit  of  the 
same  explanation  as  the  preceding  three,  I  am  unable  to  say,  but 
whether  they  do  or  do  not,  they  are  too  exceptional  in  their  character 
to  prejudice  the  argument  materially  which  we  shall  hereafter  make 
in  favor  of  resection. 

Non- Reduction. — On  the  other  hand,  it  will  be  very  difficult  to  find 
an  equal  number  of  cases  of  compound  dislocations,  unreduced,  which 
have  terminated  favorably.  The  fact  is  no  doubt  that  at  the  present 
day  very  few  surgeons  would  feel  themselves  justified  in  leaving  a 
bone. out  of  place  unless  they  proceeded  to  amputate.  In  the  Trans- 
actions of  the  New  York  State  Medical  Society  for  1855,  I  have  re- 
ported (Case  16  of  Tibia  and  Fibula,  p.  87),  a  compound  dislocation 
at  the  ankle-joint,  which,  being  unreduced,  terminated  fatally  on  the 
twenty-eighth  day.  This  is  the  only  example  of  a  compound  dislo- 
cation of  a  long  bone,  left  unreduced,  which  has  fallen  under  my  ob- 
servation ;  excepting,  of  course,  those  cases  in  which  amputation  was 
immediately  practised. 

The  united  testimony,  however,  of  the  old  surgeons,  who  generally 
neither  amputated  nor  adopted  the  method  of  resection,  but  who  re- 
commended and  practiced  non-reduction,  is,  that  it  is  much  more  safe 
to  leave  these  bones  unreduced,  than  to  reduce  them  without  resec- 
tion ;  and  I  see  no  reason  to  doubt  the  correctness  of  their  opinions 
in  this  matter.  But  whether  it  would  be  more  safe  to  leave  such 
limbs  unreduced,  or  having  practiced  resection  to  restore  them,  is 
another  question,  in  which  the  advantage  and  comparative  safety  of 
the  latter  practice  is  too  obvious  to  require  explanation  or  defence. 

Amputation. — Says  Pott:  "When  this  accident  (dislocation  of  the 
ankle)  is  accompanied,  as  it  sometimes  is,  with  a  wound  of  the  integu- 
ments of  the  inner  ankle,  and  that  made  by  the  protrusion  of  the  bone, 
it  not  unfrequently  ends  in  a  fatal  gangrene,  unless  prevented  by 
timely  amputation,  though  I  have  several  times  seen  it  do  very  well 
without."     And  Sir  Astley  Cooper,  speaking  of  compound  disloca- 

'  Hurd,  BuflFalo  Med.  Journ.,  voL  ix.  p.  119. 

2  Miller  and  Hoffman,  London  Med.  Rej)os.,  vol.  xxiv.  p.  346. 

^  Gralli,  Malgaigne,  op.  cit.,  t.  ii.  p.  958. 


^  COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.         721 

tions  of  the  ankle-joint,  remarks :  "  Thirty  years  ago  it  was  the  prac- 
tice to  amputate  limbs  for  this  accident,  and  the  operation  was  then 
thought  absolutely  necessary  for  the  preservation  of  life,  by  some  of 
our  best  surgeons."  Nor  is  it  difficult  to  see  by  what  reasoning  sur- 
geons of  "  thirty  years  ago"  had  fallen  back  upon  this  desperate  remedy. 
Both  reduction  and  non-reduction  having  proven  eminently  hazard- 
ous, in  the  absence  of  perhaps  both  knowledge  and  experience  in  re- 
section, they  finally  adopted  the  alternative  of  amputation,  as  that 
which  after  all  must  give  to  the  patient  the  best  chance  for  life;  and 
were  no  other  alternatives  to  be  presented,  this  would  be  our  choice 
in  a  large  proportion  of  cases. 

It  must  not  be  understood,  however,  that  amputation  is  an  expedient 
wholly  free  from  danger;  or,  indeed,  that  the  chances  of  the  patient 
are  in  the  average  very  greatly  increased  by  this  practice.  Of  thirteen 
amputations  made  for  compound  dislocations  at  the  ankle-joint,  in  the 
Eoyal  Infirmary  at  Edinburgh,  only  two  resulted  in  the  recovery  of 
the  patients.'  Alluding  to  which,  Mr.  Fergusson  remarks:  "An 
amount  of  mortality  which  may  well  incline  the  surgeon  to  act  upon 
the  doctrine  inculcated  by  Sir  Astley  Cooper."  (To  attempt  to  save 
the  limb  by  reduction.)  But  Mr.  Fergusson  has  added  a  sentiment 
which  accords  very  closely  with  my  own  experience  and  opinions. 
"  I  fear,  however,  that  in  the  attempts  which  have  been  made  to  save 
the  foot  (by  reduction)  the  results  in  all  the  cases  have  not  met  with 
the  same  publicity;  that  the  instances  where  amputation  has  been 
afterwards  necessary,  or  where  death  has  been  the  consequence,  have 
not  always  been  recorded;  and,  from  what  I  have  myself  seen,  I  would 
caution  the  inexperienced  practitioner  from  being  over-sanguine  in 
anticipating  a  happy  result  in  every  example." 

By  Tenotomy. — As  a  means  of  overcoming  the  resistance  of  the  mus- 
cles, and  for  the  purpose  especially  of  facilitating  the  reduction,  teno- 
tomy has  been  proposed.  First  by  Dieff'enbach  in  cases  of  ancient 
unreduced  luxations ;  but  Wm.  Hey,  Jr.,  was  the  first  to  make  a  prac- 
tical application  of  this  suggestion  in  a  case  of  compound  dislocation. 
After  cutting  the  tendo-AchiUis,  the  ankle  being  dislocated,  the  reduc- 
tion was  easily  effected,  but  a  strong  tendency  to  displacement  back- 
wards remained,  and  he  was  obliged  afterwards  to  cut  the  tendons  of 
the  tibialis  posticus  and  flexor  longus  digitorum.^ 

This  method,  based  in  some  degree  upon  a  very  correct  notion  of 
the  principal  sources  of  difficulty,  I  regard  as  totally  impracticable,  at 
least  to  any  useful  or  adequate  extent.  In  order  to  be  efficient,  all 
the  tendons  passing  the  articulations  must  be  cut,  or  nearly  all  of 
them:  and  I  doubt  whether  the  judgment  of  any  discreet  surgeon  will 
ever  sanction  such  an  extreme,  I  might  almost  say,  such  an  absurd 
measure.  Nor  do  I  think  that  in  the  point  of  view  in  which  we  are 
now  considering  this  subject,  having  reference  only  to  the  question  of 
danger,  if  the  cutting  of  the  tendons  was  sufficiently  extensive  to  have 
any  real  effect  in  facilitating  the  reduction,  the  practice  would  be  found 

'  Edinb.  Med.  Monthly,  Aug.  1844. 

^  Hey,  Trans,  of  Proviuc.  Med.  and  Surg.  Assoc,  voL  xii.  p.  1/1, 1844. 

4(5 


722  COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES 

to  have  any  advantage  over  other  methods  known  to  be  eminently 
dangerous. 

By  Resection. — Finally,  resection  presents  itself  for  our  consideration 
as  the  only  remaining  surgical  expedient. 

We  have  seen  that  most  of  the  early  writers  understood  the  effects 
of  a  constant  strain  upon  the  muscles  in  increasing  the  danger  of 
spasms,  inflammation,  and  death ;  but  in  general  they  have  suggested 
no  remedy  but  non-reduction  or  amputation.  Hippocrates,  however, 
uses  the  following  language,  after  speaking  of  resection  of  protruding- 
bones  in  accidental  amputations,  or  in  fractures  of  the  fingers:  "Com- 
plete resections  of  bones  at  the  joints,  whether  the  foot,  the  hand,  the 
leg,  the  ankle,  the  forearm,  the  wrist,  for  the  most  part,  are  not  attended 
with  danger,  unless  one  be  cut  off  at  once  by  deliquium  animi,  or  if 
continual  fever  supervene  on  the  fourth  day."  To  which  passage  the 
translator  adds  the  following  note :  "  This  paragraph  on  resection  of 
the  bones  in  compound  dislocations  and  fractures  contains  almost  all 
the  information  on  the  subject  which  is  to  be  found  in  the  works  of 
ancient  medicine."  Celsus  notices  the  practice  of  resection  in  com- 
pound dislocations  very  briefly,  as  follows :  "  Si  nudum  os  eminet, 
irapedimentum  semper  futurum  est ;  ideo  quod  excedit,  abscindendum 
est." 

Mr.  Hey,  of  Leeds,  was  the  first  of  modern  surgeons  who  called 
especial  attention  to  the  value  of  resection  in  compound  dislocations. 

Subsequently,  Mr.  Parks,  of  Liverpool,  in  an  "Account  of  a  new 
method  of  treating  Diseases  of  the  Joints  of  the  Knee  and  Elbow," 
advocates  the  practice  of  resection  in  certain  cases  of  diseases  of  these 
joints,  but  especially  in  "  affections  of  the  joints  produced  by  external 
violence." 

Mr.  Leveille,  in  France  also,  following,  as  he  afl&rms,  the  guidance 
of  Hippocrates,  has  advocated  a  similar  practice. 

Yelpeau,  Syme,  Fergusson,  Erichsen,  Miller,  Liston,  Chelius,  Lizars, 
Gibson,  Norris,  under  certain  circumstances,  and  especially  where  the 
bones  cannot  otherwise  be  reduced,  and  where  the  dislocations  occur 
in  certain  joints,  and  especially  the  elbow  and  ankle-joints,  recommend 
resection.  To  which  names  we  may  add  that  of  Sir  Astley  Cooper, 
who  has  considered  the  subject,  as  applied  to  the  ankle-joint,  quite  at 
length,  and  who  says :  "  I  have  known  no  case  of  death  when  the  ex- 
tremities of  the  bone"  (tibia,  at  the  ankle)  "have  been  sawed  off, 
although  T  shall  have  occasion  to  mention  some  cases  which  termi- 
nated fatally  when  this  was  not  done." 

Why  resection  should  diminish  the  danger  to  life,  by  placing  at  rest 
the  injured  muscles,  has  been  already  sufficiently  considered ;  but  it 
seems  not  improbable  that,  if  synovial  membranes  are  actually  more 
susceptible  of  violent  and  dangerous  inflammations  than  the  other 
tissues  about  the  joints,  then  would  this  source  of  danger  be  removed 
just  in  proportion  as  the  synovial  membranes  themselves  are  removed. 
Such,  indeed,  was  the  argument  used  by  Sir  Astley;  and  Mr.  South, 
in  a  note  to  Chelius,  when  referring  to  this  fact,  has  made  the  follow- 
ing statement : — 

"In  compound  dislocations  of  the  ankle-joint,  with  protrusion  of  the 


COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES.         723 

shin-bone  through  the  wound,  most  English  surgeons  saw  off  the  joint 
end,  not  merely  to  render  reduction  more  easy,  but  also,  according  to 
Sir  Astley  Cooper's  opinions,  to  lessen  the  suppurative  process,  by 
diminishing  the  synovial  surface.  This  mode  of  practice  is  certainly 
not  commonly  followed  in  reference  to  other  joints,  and  the  younger 
Cline  was  always  opposed  to  its  being  resorted  to  in  dislocated  ankle." 

The  following  case,  having  occurred  under  my  own  eye,  will  serve 
to  illustrate  the  value  of  the  principle  which  I  have  been  endeavoring 
to  establish : — 

Samuel  Adamson,  of  Buffalo,  set.  24,  was  caught  by  the  cable  of  a 
vessel,  June  17, 1855,  dislocating  the  left  tibia  at  its  lower  end  inwards, 
and  breaking  the  fibula  two  inches  above  the  ankle.  I  was  immedi- 
ately called,  and  found  the  tibia  protruding  through  the  skin  about 
three  inches.  The  periosteum  was  torn  up,  and  the  cartilaginous  sur- 
face of  the  end  of  the  bone  was  roughened.  His  thigh  was  also 
severely  bruised  and  lacerated,  but  the  bone  was  not  broken. 

Dr.  Boardman  assisting  me,  we  attempted  to  reduce  the  bones,  but 
with  our  hands  we  found  it  impossible  to  do  so.  I  proceeded  imme- 
diately to  remove  about  one  inch  and  a  half  of  the  lower  end  of  the 
tibia  with  the  saw.  The  remaining  portion  was  then  brought  easily 
into  place,  and  the  wound  dressed  with  sutures,  adhesive  straps,  band- 
ages, and  light  splints.  On  the  same  day  he  became  an  inmate  of  the 
marine  wards  at  the  Hospital  of  the  Sisters  of  Charity,  and  was  placed 
under  the  care  of  Dr.  Wilcox,  through  whose  politeness  I  was  permitted 
to  see  him  frequently. 

The  wound  in  the  leg  healed  kindly,  with  only  a  slight  amount 
of  inflammation  and  suppuration.  Violent  inflammation,  however, 
occurred  in  the  thigh,  followed  by  extensive  suppuration  and  slough- 
ing. This,  in  fact,  proved  to  be  by  far  the  most  serious  injury,  and 
that  which  most  endangered  his  life  and  delayed  his  recovery. 

After  about  two  months,  the  ankle  was  in  such  a  condition  as  to  re- 
quire little  or  no  further  attention.  The  fragments  of  the  fibula  had 
shortened  upon  each  other  and  were  united,  so  that  the  tibia  rested 
upon  the  astragalus.  It  was  nearly  two  months,  however,  before  he 
began  to  walk,  owing  to  the  condition  of  his  thigh, 

Aug.  24,  1856,  fourteen  months  after  the  accident,  Adamson  called 
at  my  office.  He  was  then  employed  again  as  a  sailor  on  board  the 
schooner  Sebastopol,  and  performed  all  the  duties  of  an  ordinary  deck 
hand.  His  leg  is  shortened  one  inch  and  a  quarter;  from  which,  it 
seems,  that  there  has  been  some  deposit  upon  the  end  of  the  bone, 
which  has  compensated  for  one-quarter  of  an  inch  of  that  which  I  re- 
moved. The  ankle  is  perfect  in  its  form,  being  neither  turned  to  the 
right  nor  to  the  left,  and  he  treads  square  and  firm  upon  the  sole  of 
his  foot.  There  is  considerable  freedom  of  motion,  especially  in  flexion 
and  extension.  Occasionally  it  becomes  a  little  swollen  and  painful. 
In  a  case  of  compound  dislocation  of  the  upper  end  of  the  humerus, 
occurring  also  under  my  own  observation,  and  recorded  in  the  Trans- 
actions of  the  New  York  State  Medical  Society  for  1855  (p.  27,  Case  14), 
in  which  reduction  was  followed  by  death,  I  have  now  much  reason 
to  believe  that  if  I  had  practiced  resection  before  the  reduction,  my 


724         COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

patient's  chances  for  recovery  would  have  been  greatly  increased ; 
perhaps  also  the  case  of  compound  dislocation  at  the  wrist-joint  re- 
corded in  the  same  vol.  (p.  68),  in  which,  having  reduced  the  bones, 
I  was  subsequently  compelled  to  amputate,  may  equally  illustrate  the 
hazard  to  which  the  practice  of  reduction  without  resection  must  often 
expose  the  patient. 

The  same  remarks  I  will  venture  to  apply  to  tbe  case  of  compound 
dislocation  of  the  hip,  of  which  I  have  already  spoken  as  having  oc- 
curred in  the  practice  of  Dr.  Walker,  of  Charlestown,  Mass.  Had  the 
head  of  the  femur  been  resected  before  its  reduction,  I  cannot  doubt 
but  that  the  unfortunate  man's  chances  for  recovery  would  have  been 
very  greatly  improved. 

Thus,  if  we  consider  the  question  of  the  life  of  the  patient  only,  the 
argument  and  the  testimony  seem  to  favor  resection  in  a  great  major- 
ity of  cases  of  compound  dislocations  occurring  in  large  joints,  and 
in  a  considerable  number  of  cases  of  similar  accidents  in  the  smaller 
joints.  It  is  certainly  more  safe  than  non-reduction  or  reduction 
without  resection,  and  it  is  probably  quite  as  safe  as  amputation  or 
tenotomy. 

But  there  is  another  question,  which  is,  in  our  estimation,  secondary 
to  the  one  now  considered,  but  which  is  often  in  the  estimation  of  the 
patient  himself,  of  the  first  importance — namely,  by  which  method 
will  he  suffer  the  least  maiming  or  mutilation  ? 

This  question  I  do  not  find  it  difficult  to  answer.  Certainly  it  is 
not  by  non-reduction  or  by  amputation;  and,  putting  tenotomy  aside, 
it  is  now  a  question  only  between  reduction  without  resection,  and 
reduction  with  resection.  These  two  methods,  one  of  which  experience 
has  shown  to  be  fraught  with  danger,  and  the  other  of  which  expe- 
rience has  shown  to  be  relatively  safe,  are  now  to  be  compared  in  a 
point  of  view  in  which  their  antagonisms  are  perhaps  less  conspicuous, 
yet  sufficiently  marked. 

First.  In  either  case  the  inflammation  consequent  upon  the  injury 
may  be  violent,  and  the  recovery  slow  and  tedious.  The  same  argu- 
ments, however,  which  we  have  applied  to  the  question  of  the  com- 
parative danger  of  the  two  modes,  must  apply  with  nearly  equal  force 
to  this  question  of  maiming ;  since  the  amount  of  maiming  must  often 
be  governed  by  the  intensity  and  duration  of  the  inflammation,  and 
upon  this  point  the  testimony  has  been  shown  to  be  in  favor  of 
resection. 

It  will  be  observed  that  not  only  is  the  danger  of  maiming  rendered 
more  considerable  by  reduction  without  resection,  because  the  inflam- 
mation is  so  much  more  likely  to  extend  to  the  tendons  and  muscles, 
causing  them  to  adhere  to  each  other,  and  to  become  subsequently 
atrophied,  a  condition  from  which  they  often  never  completely  recover, 
but  also  because  the  ligaments  and  capsules  of  the  joints,  with  the 
synovial  surfaces,  are  in  consequence  encroached  upon,  and  the  free- 
dom of  motion  is  ever  afterwards  greatly  restricted,  if  not  completely 
lost.  This  marked  impairment  of  the  functions  of  the  joint  does  not 
always  happen,  but  it  cannot  be  denied  that  it  does  generally.  Indeed 
it  is  by  no  means  uncommon  for  these  accidents  to  be  followed,  after 


COMPOUND    DISLOCATIOXS    OF    THE    LOXG    BONES.         725 

yilcerations  of  the  cartilage,  by  copious  bony  deposits  in  and  around  the 
joints. 

How  is  it,  on  the  other  hand,  with  these  joints  after  resection?  I 
have  thus  far  heard  of  no  cases  in  which  complete  anchylosis  resulted  ; 
but  in  all  considerable  freedom  of  motion  has  returned,  and  in  some 
the  restoration  in  this  respect  has  been  nearly  or  quite  as  complete  as 
before  the  accident. 

Says  Dr.  Kerr,  of  Northampton:  "Several  cases  of  compound 
dislocation  of  the  ankle  have  fallen  under  my  care,  and  it  has  been 
uniformly  my  practice  to  take  off  the  lower  extremity  of  the  tibia, 
and  to  lay  the  limb  in  a  state  of  semiflexion  upon  splints :  by  this 
means  a  great  deal  of  painful  extension,  and  the  consequent  high 
degree  of  inflammation,  are  avoided.  The  splints  I  used  are  excavated 
wood,  and  much  wider  than  those  in  common  use,  with  thick  movable 
pads  stuffed  with  wool.  I  keep  the  parts  constantly  wetted  with  a 
solution  of  liquor  ammonia  acetatis,  without  removing  the  bandage. 
In  my  very  early  life,  upwards  of  sixty  years  ago,  I  saw  many 
attempts  to  reduce  compound  dislocations  without  removing  any  part 
of  the  tibia  ;  but,  to  the  best  of  my  recollection,  they  all  ended  un- 
favorably, or,  at  least  in  amputation.  By  the  method  which  I  have 
pursued,  as  above  mentioned,  I  have  generally  succeeded  in  saving 
the  foot,  and  in  preserving  a  tolerable  articulation." 

Sir  Astley  Cooper  has  made  a  valuable  experiment  to  determine 
the  condition  of  the  new  joint  under  these  circumstances;  and  the 
vast  number  of  cases  in  which  resection  has  now  been  practiced  in 
cases  of  caries  of  the  articulating  surfaces,  and  their  results,  add  still 
more  substantial  proofs  as  to  the  usefulness  of  the  joints  after  such 
operations, 

"  I  made  an  incision  upon  the  lower  extremity  of  the  tibia,  at  the 
inner  ankle  of  a  dog,  and  cutting  the  inner  portion  of  the  ligament  of 
the  ankle-joint,  I  produced  a  compound  dislocation  of  the  bone  in- 
wards. I  then  sawed  off  the  whole  cartilaginous  extremity  of  the 
tibia,  returned  the  bone  upon  the  astragalus,  closed  the  integuments 
by  suture,  and  bandaged  the  limb  to  preserve  the  bone  in  this  situa- 
tion. Considerable  inflammation  and  suppuration  followed  ;  and  in  a 
week  the  bandage  was  removed.  When  the  wound  had  been  for 
several  weeks  perfectly  healed,  I  dissected  the  limb.  The  ligament 
of  the  joint  was  still  defective  at  the  part  at  which  it  had  been  cut. 
From  the  sawn  surface  of  the  tibia  there  grew  a  ligamento-carti- 
laginous  substance,  which  proceeded  to  the  surface  of  the  cartilage 
of  the  astragalus  to  which  it  adhered.  The  cartilage  of  the  astra- 
galus appeared  to  be  absorbed  only  in  one  small  part ;  there  was  no 
cavity  between  the  end  of  the  tibia  and  the  cartilaginous  surface  of  the 
astragalus.  A  free  motion  existed  between  the  tibia  and  astragalus 
which  was  permitted  by  the  length  and  flexibility  of  the  ligamentous 
substance  above  described,  so  as  to  give  the  advantage  of  a  joint  where 
no  synovial  articulation  or  cavity  was  to  be  found.  This  experiment 
not  only  shows  the  manner  in  which  the  parts  are  restored,  but  also 
the  advantage  of  passive  motion  ;  for  if  the  part  be  frequently  moved, 
the  intervemng  substance  becomes  entirvjly  ligamentous  ;   but  il  it  be 


726         COMPOUND    DISLOCATIONS    OF    THE    LONG    BONES. 

left  perfectly  at  rest  for  a  length  of  time,  ossific  action  proceeds  from 
the  extremity  of  the  tibia  into  the  ligamentous  substance,  and  thus 
produces  an  ossific  anchylosis." 

_  Second.  Is  it  not  probable,  moreover,  since  the  limb  can  be  retained 
in  place  so  much  more  easily  after  resection,  that  it  will  actually,  in  a 
majority  of  cases,  be  found  to  have  been  retained  in  place  more  per- 
fectly ?  Even  after  simple  dislocations,  especially  in  those  occurrino- 
at  the  ankle-joint,  great  deformity  and  much  maiming  are  the  nol 
unfrequent  results,  and  that  too  when  all  diligence  and  care  have  been 
employed.  It  has  been  impossible  always  to  maintain  a  perfect  appo- 
sition m  the  articulating  surfaces.  How  much  greater  must  be  this 
difficulty  in  cases  of  compound  dislocations! 

Third.  The  only  argument  which  remains  in  favor  of  reduction 
without  resection  is  the  necessary  shortening  of  the  limb  after  resec- 
tion. But  this  need  seldom  perhaps  to  exceed  three-quarters  of  an 
inch,  and  often  not  more  than  half  an  inch ;  an  amount  of  shortening 
which,  as  I  have  had  occasion  to  prove  when  treating  of  fractures' 
does  not  necessarily  produce  a  halt,  and  which  indeed  is  often  not 
known  to  exist  by  the  patient  himself. 

Finally.  It  must  not  be  inferred  that  the  author  intends  to  recom- 
mend resection  as  a  universal  practice  in  cases  of  compound  disloca- 
tions of  the  long  bones.  He  has  only  sought  to  determine  in  a  general 
manner  its  relative  value  as  compared  with  other  modes  of  procedure; 
and  especially  has  it  been  his  intention  to  bring  more  prominently 
into  view  the  importance  of  rest  and  relaxation  to  the  muscles,  as  an 
element  in  the  _  treatment  most  essential  to  success.  To  declare  its 
special  application  to  cases  would  demand  a  treatise  more  elaborate 
than  it  was  proposed  to  write.  If,  however,  one  were  to  speak  of  the 
individual  bones  only,  there  seems  sufficient  authority  in  the  facts  and 
arguments  already  presented  to  conclude  that  resection  is  applicable 
to  certain  compound  dislocations  of  the  clavicle,  humerus,  radius  and 
ulna,  fingers,  femur,  tibia  and  fibula,  and  toes;  in  short  to  all  of  these 
accidents  occurring  in  the  long  bones  of  the  extremities. 

If  an  attempt  is  made  to  save  the  limb  without  resection,  it  is  scarcely 
necessary  to  say  that  the  success  will  depend,  in  a  great  measure,  upon 
thecare,  attention,  and  skill  bestowed  upon  the  treatment.  Cool  or 
tepid  water-dressings,  according  as  the  indications  or  the  sensations  of 
the  patient  seem  to  demand,  are  among  the  most  valuable  remedial 
agents.  The  limb  must  be  maintained  in  a  position  of  rest,  combined 
with  moderate  elevation  ;  and  the  bran-dressings,  recommended  in 
compound  fractures,  will  be  found  occasionally  useful. 


CONGENITAL    DISLOCATIONS.  727 


CHAPTER    XXVI. 

CONGENITAL  DISLOCATIONS. 

§  1.  General  Observations  and  History. 

We  have  omitted,  until  this  moment,  to  speak  of  Congenital  Dislo- 
cations, because,  whatever  theory  of  causation  we  adopt,  dissections 
have  shown  that  they  are  generally,  in  some  sense,  pathologic,  or  are 
accompanied  with  such  essential"  modifications  of  the  anatomical  struc- 
tures as  to  separate  them  entirely  from  ordinary  traumatic  luxations, 
which  alone  constitute  the  proper  subjects  of  consideration  in  the  pre- 
sent treatise.  In  relation  to  congenital  dislocations,  we  shall  find  it 
necessary  to  establish  systems  of  etiology,  symptomatology,  prognosis, 
and  treatment,  having  very  few  points  in  common  with  traumatic  dis- 
locations. Exceptions  to  this  rule  will  occur,  in  examples  of  intra- 
uterine traumatic  luxations,  existing  at  birth  without  either  original 
or  accidental  malformations  of  the  articulations,  or  of  the  adjacent 
muscular,  tendinous,  or  ligamentous  structures;  yet  only  in  sufficient 
numbers  to  warrant  the  intrusion  of  the  subject  in  this  place. 

It  is  probable  that  congenital  displacements  may  occur  m  all  the 
articulations  of  the  skeleton;  and  in  most  of  them  their  existence  has 
been  already  established  by  dissections.  Until  withm  a  fewyears 
however,  the  attention  of  surgeons  has  been  almost  entirely  directed 
to  concrenital  dislocations  of  the  shoulder  and  hip. 

Hippocrates,  in  his  treatise  "De  Articulis,"  speaks  expressly  of  dis- 
locations of  the  hip  occurring  in  the  mother's  womb,  comprismg  them 
under  the  same  order  with  the  different  varieties  of  club-toot 

Avicenna  and  Ambrose  Par^  have  each  mentioned  original  disloca- 
tions of  the  hip ;  but  the  first  to  record  an  example  with  any  degree 
of  accuracy  was  Kerkring;  in  which  case,  death  having  occurred 
during  infancy,  he  was  able  to  verify  his  opinion  by  an  autopsy. 
Ghaussier  has  reported,  in  the  Bulletin  de  la  Faculte  et  (k  la  Societe  de 
Medecine,  An.  1811  and  1812,  the  case  of  an  infant,  upon  which  he 
discovered,  at  birth,  two  dislocations,  one  ^V^^.^.^f  ^^°-^r''TAr.T.n' 
culation,  aid  the  other  at  the  coxo-femoral.  In  1788,  Paletta  of  Milan 
published,  under  the  title  of  Adversaria  Ghirurgica  a  collection  of 
<\bservations,  in  which,  among  other  things,  he  '^}^\l^'^'^'^?f'l^;. 
congenital  malformations  of  the  hip-jomt;  and  m  1820,  he  publ  shed 
another  work,  entitled  Exercitationes  Paihologicce  where  he  enters  into 
a  more  complete  exposition  of  the  nature  and  causes  of  these  de- 

^Xl826,  Dupuytren  read,  before  the  Academy  of  Sciences,  a  memoir 
npon  the  lameness  produced  by  the  orionnal  displacement  of  he 
femurs;  and  in  the  Uons  Orales,  published  m  the  collections  of  the 


728  CONGENITAL    DISLOCATIONS. 

Sydenham  Society,  may  be  found  a  full  record  of  the  views  and  obser- 
vations of  this  distinguished  surgeon. 

The  writings  of  Dupuytren  seem,  more  than  anything  previously 
written,  to  have  directed  the  attention  of  surgeons  and  pathologists  to 
this  interesting  subject,  and  to  have  given  a  new  impulse  to  investi- 
gation, 

From  this  time,  various  treatises  have  been  written  by  eminent 
surgeons,  many  of  which  are  characterized  by  profound  thought,  care- 
ful investigation,  and  practical  experiment. 

Among  those  who  have  furnished  us  lately  with  elaborate  treatises, 
or  with  more  precise  practical  information  upon  this  subject,  the  fol- 
lowing names  deserve  especially  to  be  mentioned  :  Breschet,^  Caillard- 
Billioni^re,^  Lehoux,^  Sandiforte,^  Duval  and  Lafond,  Humbert  and 
Jacquier,  Bouvier,*  Sedillot,^  Gerdy,  Poliniere,  Wrolik,^  Guerin,^  Pa- 
rise,^  Pravaz,^°  Carnochau,"  and  flobe'rt  Smith.^^ 


§  2.  Etiology, 

Hippocrates  says  that  the  bones  of  the  extremities  may  be  disar- 
ticulated during  intra-uterine  life  by  falls  or  blows,  or  by  injuries  of 
any  kind,  inflicted  directly  upon  the  abdomen  of  the  mother. 

Ambrose  Par6,  while  admitting  the  efficiency  of  the  several  causes 
named  by  Hippocrates,  believed  also  that  the  contractions  of  the 
womb,  and  violence  employed  by  the  accoucheur  were  occasionally 
adequate  to  the  production  of  the  same  results.  He  taught,  moreover, 
that  the  position  of  the  foetus  itself  might  favor  the  displacement; 
and  that,  in  some  instances,  an  articular  abscess,  insufficient  depth  of 
the  socket  with  a  laxity  of  the  ligaments,  were  competent  to  determine 
the  expulsion  of  the  head  of  the  femur  from  its  natural  position. 

Sedillot  regards  a  softening  and  relaxation  of  the  ligaments  as  the. 
most  frequent  cause. 

Parise  and  Malgaigne  are  disposed  to  attribute  a  majority  of  these 
cases  to  hydrarthrosis,  or  water  in  the  joints.  Says  Malgaigne:  "For 
myself,  after  having  long  meditated  upon  this  subject,  I  have  come  to 
think  that  inflammation  of  the  joints  enjoys  a  grand  role,  both  in 
coxo-femoral  dislocations  and  in  many  others,  and  even  also  in  various 

'  Breschet,  Repertoire  d'Anatomie  et  de  Physiologie. 

^  Caillard-Billioniere,  These  Inangurale,  1828. 

^  Lehoux,  These  Inaugurale,  1834,  Paris. 

*  Sandiforte,  Thesis,  Sustained  belore  the  Faculty  of  Med.  of  Leyden'. 

^  Duval  and  Lafond,  Humbert  and  .Jacquier,  Bouvier.     See  Pravaz, 

^  Sedillot,  Journ.  de  Connais.  Med.-Chirurg.,  1838. 

'  Gerdy,  Poliniere,  Wrolik.     See  Pravaz. 

8  Guerin,  Recherches  sur  les  Luxations  Congenitales ;  par  Jules  Guerin,  Paris,  1841. 

9  Parise,  Archiv.  Gen.  de  Med.,  1842. 

1°  Pravaz,  Traite  Theorique  et  Pratique  des  Luxations  Congenitales  du  Femur,  suivi 
d'un  Appendice  sur  la  Prophylaxie  des  Luxations  Spontanees  ;  par  Ch.  G.  Pravaz, 
Lyon,  1847. 

"  Carnochan,  A  Treatise  on  the  Etiology,  Pathology,  and  Treatment  of  Congenital 
Dislocations  of  the  Head  of  the  Femur;  by  John  Murray  Carnochan,  New  York,  1850. 

'^  R.  Smith,  A  Treatise  on  Fractures  in  the  Vicinity  of  Joints,  and  on  Certain  Acci- 
dental arid  Congenital  Dislocations,  Dublin,  1854. 


ETIOLOGY.  729 

congenital  malformations  generally  ascribed  to  arrest  of  development." 
This  witer  admits,  however,  that  it  will  not  do  to  generalize  too  much 
in  this  matter,  and  that  the  etiology  of  congenital  luxations  is  pro- 
bably as  complex  as  that  of  luxations  after  birth. 

Chaussier  seems  to  have  regarded  muscular  contraction,  or  the 
occurrence  of  an  intra-uterine  convulsion,  as  the  cause  of  the  example 
of  congenital  dislocation  of  both  humerus  and  femur  seen  and  recorded 
by  him.  Since  whom  Guerin  has  greatly  extended  the  application 
of  this  doctrine,  having  embraced  in  the  same  etiologic  formula  all 
or  nearly  all  congenital  dislocations.  Guerin  ascribes  to  muscular 
contraction  in  one  form  or  another,  and  to  corresponding  muscular 
paralysis,  not  only  dislocations  of  the  femur  and  other  long  bones, 
but  also  club-foot,  torticollis,  and  various  other  deviations  of  the  spine! 
He  affirms,^  moreover,  that  he  has  established  incontestably  the  depend- 
ence of  this  abnormal  state  of  the  muscular  system  upon  the  absence 
or  disappearance  more  or  less  complete  of  corresponding  portions  of 
the  central  nervous  systems. 

Breschet  and  Delpech  maintained  similar  views,  especially  in  rela- 
tion to  the  dependence  of  the  several  varieties  of  club-foot  upon  some 
morbid  condition  of  the  cerebro-spinal  axis.  While  Carnochan 
remarks  as  follows :  "It  appears  most  in  accordance  with  science  to 
refer  the  muscular  spasmodic  retraction,  upon  which  congenital  dis- 
locations of  the  head  of  the  femur  from  the  cotyloid  cavity  depend, 
to  a  perverted  condition  of  the  excito-motor  apparatus  of  the  medulla 
spinalis,  and  more  especially  of  that  portion  of  it  which  is  in  direct 
relation  with  the  reflex-motor  nervous  fibres,  distributed  to  the  pelvi- 
femoral  muscles  surrounding,  and  in  connection  with,  the  ilio-femoral 
articulation." 

Palletta  ascribes  these  deformities  solely  to  an  original  defect  of  the 
germ  ;  and  Dupuytren  also  declares  that,  in  the  case  of  a  congenital 
dislocation  of  the  hip,  the  causes  are  coeval  with  the  earliest  organiz- 
ation of  the  parts,  and  that  the  displacement  is  due  rather  to  a  defect 
in  the  depth  or  completeness  of  the  acetabulum,  than  to  accident  or 
disease. 

Breschet  and  Delpech,  both  of  whom,  as  we  have  already  stated, 
refer  them  to  some  morbid  condition  of  the  cerebro-spinal  axis,  ima- 
gine that  in  consequence  of  this  morbid  condition  of  the  nervous 
centres  there  exists  an  arrest  of  development  in  the  bones,  muscles, 
ligaments,  sockets,  and,  in  short,  through  all  the  apparatus  of  the  joint 
which  is  the  seat  of  the  deformity. 

If  we  proceed  to  analyze  these  various  opinions,  we  shall  find  that 
they  are  so  far  susceptible  of  classification,  as  that  they  may  be  arranged 
under  the  three  following  divisions. 

First,  the  physiological  doctrines ;  according  to  which  congenital 
dislocations  are  due  to  an  original  defect  in  the  germ,  or  to  an  arrest 
of  development. 

Second,  the  pathologic  doctrines;  which  refer  them  to  some  sup- 
posed lesion  of  the  nervous  centres,  to  contraction  or  paralysis  of  the 
muscles,  to  a  laxity  of  the  ligaments,  to  hydrarthrosis,  or  to  some  other 
diseased  condition  of  the  articulating  apparatus. 


730  CONGENITAL    DISLOCATIONS. 

Third,  the  mechanical  doctrines ;  which  recognize  no  intra-uterine 
dislocations  except  those  which  are  strictly  traumatic.  The  causes 
being  understood  to  be  the  peculiar  position  of  the  foetus  in  utero, 
violent  contractions  or  the  constant  pressure  of  the  walls  of  the  uterus, 
falls  and  blows  upon  the  abdomen,  and  unskilful  manipulation  of  the 
child  in  delivery. 

After  a  full  and  careful  consideration  of  this  subject,  we  are  pre- 
pared to  admit  the  occasional  agency  of  all  the  causes  enumerated, 
and  the  probable  concurrence  of  two  or  more  in  many  instances;  nor 
do  we  see  the  propriety  of  rejecting,  as  Malgaigne  has  done,  all  that 
large  class  of  malformations  which  seem  to  depend  upon  an  arrest  of 
development,  or  those  which  appear  to  be  due  mainly  or  solely  to 
intra-uterine  paralysis,  of  both  of  which  many  examples  have  been 
reported. 


§  3.  Congenital  Dislocations  or  the  Inferior  Maxilla. 

Malgaigue  affirms  that  "  we  know  of  no  congenital  dislocation  of 
the  jaw,"  and  that  we  are  "  not  to  take  seriously  the  pretended  luxa- 
tion observed  by  Guerin  upon  a  derencephalous  infant."  The  example 
recorded  by  Robert  Smith  he  rejects  also,  declaring  that  he  does  "not 
comprehend  how  one  can  see  in  it  a  luxation." 

For  myself,  1  know  of  no  reason  why  we  should  not  take  "seriously" 
the  case  mentioned  by  Gudrin,  since,  so  far  as  appears  in  his  very  brief 
report  of  the  same,  it  might  have  been  a  true  luxation.  The  specimen 
was  before  the  academy,  and  if  Malgaigne,  from  a  personal  examina- 
tion, has  become  satisfied  that  a  dislocation  did  not  exist,  he  ought  to 
have  so  informed  us.  But  since  he  does  not  speak  of  having  made 
it  the  subject  of  especial  examination,  we  shall  feel  compelled  to  accept 
of  it  as  reported  by  Guerin. 

As  to  the  objections  offered  to  Mr.  Smith's  case,  namely,  that  "  aside 
of  the  complete  absence  of  its  history,  the  subject  did  not  present  the 
characteristic  signs  of  a  luxation;  and  the  dissection  discovered 
neither  maxillary  condyle,  nor  glenoid  cavity,"  we  must  reply,  the 
dissection  seems  to  us  to  have  furnished  such  evidence  that  the  defor- 
mity was  congenital  as  to  render  its  history  unnecessary ;  the  signs 
were  characteristic,  not  indeed  of  a  traumatic  luxation,  but  of  a  con- 
genital dislocation,  such  as  may  be  supposed  to  have  been  the  result 
of  an  arrest  of  development,  or  of  an  original  aberration  of  the  germ. 

The  following  is  a  summary  of  the  very  complete  account  of  this 
case  given  by  Robert  Smith. 

On  the  fifth  of  May,  1810,  Edward  Lacy,  set.  38,  an  idiot  from  in- 
fancy, died  at  the  Hardwick  Hospital,  in  consequence  of  gangrene  of 
the  lungs.  While  making  the  autopsy,  a  singular  deformity  of  the 
face  was  discovered.  The  right  and  left  sides  seemed  as  though  they 
did  not  belong  to  the  same  individual,  the  left  being  in  every  respect 
more  fully  developed.  Upon  removing  the  integuments,  the  muscles  of 
the  right  side  were  found  to  be  much  smaller  than  those  of  the  left,  and 
especially  the  masseter.     These  latter  having  been  removed  also,  the 


CONGENITAL    DISLOCATIONS    OF    INFEKIOR    MAXILLA.       731 

condition  of  the  right  temporo-maxillarj  articulation  was  carefully 
studied. 

When  the  mouth  was  closed,  the  external  lateral  ligament,  instead 
of  being  directed  backwards,  was  seen  descending  obliquely  forwards, 
to  be  attached  to  a  very  imperfectly  developed  condyle  situated  at 
least  one-quarter  of  an  inch  in  front  of  its  natural  position.  There 
was  neither  an  inter-articular  cartilage  nor  cartilage  of  incrustation, 
the  joint  surfaces  being  invested  by  a  thick  periosteum  alone;  nor 
was  there  any  distinct  capsular  ligament. 

Nearly  the  whole  of  the  right  side  of  the  inferior  maxilla  was 
smaller  than  the  left.  The  condyle  was  short  and  curved,  being 
directed  nearly  horizontally  inwards,  and  resembling  much  more 
the  coracoid  process  than  the  condyle  of  the  inferior  maxilla.  The 
coronoid  process  was  very  small  and  thin,  and  the  sigmoid  notch  could 
scarcely  be  said  to  exist. 

The  articular  eminence  of  the  temporal  bone  was  absent,  there 
being  in  its  place  merely  a  flat  surface  destitute  of  cartilage;  which 
surface  presented  upon  its  inner  side  a  shallow  and  semicircular  sulcus 
where  the  hook-like  condyle  of  the  lower  jaw  had  played. 

The  malar,  superior  maxillary,  and  sphenoid  bones  of  the  right 
side  had  also  suffered  corresponding  changes  of  form  and  relative 
size. 

The  motions  permitted  in  the  lower  jaw  were  more  extensive  than 
those  which  it  enjoys  in  its  normal  condition,  that  is,  upon  the  right 
side  the  ramus  could  be  moved  very  freely  forwards  and  backwards, 
while  upon  the  left,  the  condyle  underwent  a  species  of  rotation  upon 
its  axis.  During  life  the  patient  was  observed  to  be  constantly  per- 
forming this  motion,  and  the  right  side  of  the  face  was  continually 
affected  with  spasmodic  twitches.  When  the  mouth  was  closed,  the 
front  teeth  of  the  upper  jaw  projected  beyond  those  of  the  lower,  and 
when  opened  the  deformity  was  in  all  respects  greatly  increased.' 

Mr.  Smith  takes  this  occasion  also  to  express  his  dissent  from  the 
views  maintained  by  Eibes,  namely,  that  the  formation  of  the  glenoid 
cavity  is  consequent  upon  the  growth  of  the  condyle,  and  that,  were 
this  process  not  formed,  there  would  not  exist  either  a  glenoid  cavity 
or  an  articular  eminence.  It  is  true  that  neither  the  glenoid  cavity 
nor  the  articular  eminence  is  found  in  the  foetus.  Until  the  seventh 
month  of  intra-uterine  life,  there  exists  at  this  point  of  the  temporal 
bone  only  a  plane  surface,  and  the  glenoid  cavity  with  its  correspond- 
ing eminence  is  developed  in  proportion  to  the  growth  and  develop- 
ment of  the  condyle.  But  Mr.  Smith  justly  observes  that  although 
the  development  of  the  condyle  does  precede  that  of  the  glenoid  cavity, 
"  it  b}^  no  means  follows  that  the  formation  of  the  latter  is  due  to  the 
pressure  of  the  former."  The  cavity,  or  rather  the  transverse  eminence 
in  front  of  the  plane  surface,  does  not  exist  in  foetal  life,  because, 
owing  to  the  peculiar  form  of  the  inferior  maxilla  at  this  period,  its 
existence  is  not  necessary.  The  vertical  portion  of  the  jaw  (vertical 
only  in  the  adult)  is  in  the  foetus  nearly  in  the  same  line  with  the  axis 

1  Robert  Smith,  op.  cit.,  p.  283. 


732  CONGENITAL    DISLOCATIONS. 

of  the  shaft,  and  consequently  when  the  mouth  is  opened  by  the  action 
of  the  muscles,  the  condyles  are  pressed  upwards  and  backwards 
instead  of  upwards  and  forwards,  as  in  the  adult.  A  displacement 
forwards  cannot  therefore  very  well  occur ;  and  the  protection  of  the 
articular  eminences  is  not  required.  As  age  advances  the  angles  of  the 
jaw  increase,  the  portions  upon  which  the  condyles  rest  become  more 
vertical,  and  finally  a  displacement  forwards  would  occur  whenever 
the  mouth  was  well  opened  if  the  articular  eminences  were  not  present 
to  afford  a  sufficient  protection  in  front. 

In  the  case  of  Lacy  the  foetal  condition  of  the  bones  upon  one  side 
remained  during  life,  there  being  neither  cavity  nor  eminence,  and 
the  condyle  itself  being  only  imperfectly  developed ;  but  the  angle  of 
the  jaw  had  assumed  the  form  which  belongs  to  the  adult,  and  the 
ascending  ramus  was  vertical,  consequently  the  condyle  became  some- 
what displaced  forwards. 

Chronic  rheumatic  arthritis  is  occasionally  found  in  the  temporo- 
maxillary  articulation  of  old  persons;  and  it  may  be  important  to 
distinguish  it  from  congenital  luxation,  with  which,  owing  to  the 
absorption  of  the  articular  eminence,  and  the  consequent  displacement 
of  the  condyle,  it  might  possibly  be  confounded. 

Says  Mr.  Smith:  "  In  a  majority  of  instances,  this  remarkable  dis- 
ease attacks  those  of  advanced  age,  and  is  symmetrical;  but  occasion- 
ally it  occurs  during  the  period  of  adult  life.  In  the  latter  case  it  is 
generally  more  rapid  in  its  progress,  is  accompanied  by  greater  pain, 
and  is  more  liable  to  implicate  the  neck  of  the  condyle,  and  the  ramus 
of  the  jaw." 

When  the  condyle  is  implicated  it  becomes  enlarged,  and  can  be 
felt  beneath  the  zygoma,  in  front  of  the  meatus  externus.  The  lym- 
phatic glands  of  this  region  are  sometimes  enlarged,  and  the  progress 
of  the  malady  is  attended  with  a  constant  but  not  generally  severe 
pain. 

The  deformity  of  the  face  varies  according  as  one  or  both  articula- 
tions are  affected.  When  the  malady  is  confined  to  one  joint,  the 
chin  is  thrown  slightly  forwards,  but  chiefly  to  the  opposite  side ;  and 
when  both  are  implicated  the  chin  is  simply  advanced  so  that  the  teeth 
project  beyond  those  of  the  upper  jaw. 

As  the  disease  progresses,  the  glenoid  cavity  enlarges  by  absorption, 
and  at  length  a  considerable  portion  or  the  whole  of  the  articular  emi- 
nence disappears,  and  the  jaw  becomes  gradually  displaced  through 
the  action  of  the  external  pterygoids.  The  disease  does  not  extend 
in  the  temporal  bone  beyond  the  articulating  surface  of  the  glenoid 
cavity.  The  condyle  assumes  a  variety  of  forms,  sometimes  being 
greatly  enlarged  in  all  its  diameters,  while  its  upper  surface  may  be 
flattened,  or  conical.  The  inter-articular  cartilage  disappears;  but 
Mr.  Smith  has  never  yet  found  any  foreign  bodies  in  the  joint,  and 
in  only  one  instance  have  the  surfaces  been  polished  or  eburnated  as 
we  often  see  in  examples  of  chronic  rheumatic  arthritis  occurring  in 
the  hip,  knee,  and  other  joints. 

The  following  is  an  excellent  summary  of  the  diagnostic  marks 


CONGENITAL    DISLOCATIONS    OF    THE    SPINE.  783 

between  congenital,  accidental,  and  rheumatic  dislocations,  given  by 
this  writer : — 

"  1.  In  the  congenital  luxation,  the  mouth  can  be  freely  opened  and 
closed;  in  chronic  rheumatism  these  motions  can  be  performed,  but 
not  without  uneasiness  to  the  patient,  an  uneasiness  which  sometimes 
amounts  to  severe  pain ;  in  luxations  from  accident,  the  mouth  can- 
not be  closed. 

_  "2.  An  involuntary  flow  of  saliva  accompanies  the  accidental  luxa- 
tion alone,  although  in  some  cases  of  chronic  rheumatism  there  is  an 
increased  secretion  of  that  fluid. 

"8.  In  congenital  luxation,  the  teeth  of  the  upper  jaw  project  be- 
yond those  of  the  lower  ;  the  reverse  is  observed  in  accidental  luxation 
and  in  chronic  rheumatism. 

"4.  In  congenital  luxation  there  is  no  fulness  in  the  cheek,  such  as 
the  coronoid  process  produces  in  cases  of  accidental  luxation,  and  the 
enlarged  condyle  in  some  instances  of  chronic  rheumatic  arthritis."^ 


§  4.  Congenital  Dislocations  or  the  Spine. 

Says  Guerin,  of  the  subluxation  occipito-atloidean  there  are  two 
varieties :  "  First.  Backwards,  consisting  in  an  exaggerated  flexion  of 
the  head,  upon  the  front  of  the  neck  and  chest,  with  a  commence- 
ment of  sliding  backwards  of  the  occipital  condyles  upon  the  articular 
facets  of  the  atlas.  Here  are  two  examples  in  foetal  enencephalous 
monsters.  Second.  Forwards.  Those  who  follow  my  consultations 
can  recollect  having  seen  last  year  an  infant,  about  two  or  three  months 
old,  who  offered  a  remarkable  example.  The  head  was  exactly  applied 
against  the  posterior  part  of  the  neck,  and  upper  part  of  the  back. 
There  was  probably  a  sliding  of  the  condyles  forwards,  with  elongation 
of  the  anterior  ligaments."^ 

The  existence  of  the  first  of  these  varieties  has  since  been  denied 
by  Gudrin  himself;^  and  it  will  be  noticed  that  he  only  speaks  of  the 
second  as  Si  probable  subluxation  forwards.  Neither  of  them  can  there- 
fore be  regarded  as  established. 

Guerin  farther  remarks  that  he  has  observed  subluxations  in  the 
other  regions  of  the  spinal  column  many  times;  and  he  showed  to  the 
Academy  a  foetus  in  which  the  spine  presented,  besides  the  occipito- 
altoidean  displacement,  a  series  of  angular  flexions  in  the  antero-pos- 
terior  direction,  with  sliding  of  the  articular  surfaces. 

In  attempting  to  appreciate  the  value  of  Guerin's  observations  upon 
this  point,  it  must  be  remembered  that  he  regards  all  cases  of  congeni- 
tal torticollis,  and  other  deviations  of  the  spine,  as  examples  of  sub- 
luxation ;  and,  in  some  sense,  we  think  the  theory  of  this  distinguished 
surgeon  may  he  regarded  as  correct.  The  amount  of  articular  dis- 
placement between  each  of  the  adjacent  vertebra  may  be  very  incon- 
siderable in  any  such  case,  yet,  however  trivial,  if  it  exceeds  the  limits 

1  R.  Smith,  op.  cit.,  p.  292.  ^  Guerin,  op.  cit.,  1841,  p.  29. 

3  Guerin,  Gaz.  Med.,  1851,  p.  227. 


734  CONGENITAL    DISLOCATIONS. 

of  natural  motion,  it  may  properly  enough  be  regarded  as  the  com- 
mencement of  a  luxation. 


§  5.  Congenital  Dislocations  of  the  Pelvic  Bones. 

Bassius  speaks  of  a  diastasis  or  separation  of  the  sacro-iliac  sym- 
physis, observed  by  him  in  newly-born  children,  and  in  infants;  but, 
according  to  Malgaigne,  his  account  of  these  cases  is  not  such  as  to 
warrant  any  conclusions  as  to  the  true  nature  of  the  displacements. 

Congenital  extrophy  of  the  bladder  is  accompanied  always  with  a 
deficiency  of  the  central  and  upper  portions  of  the  pubic  bones,  the 
result  manifestly  of  an  arrest  of  development;  but  these  cases,  of 
which  I  have  seen  two  examples,  are  not  properly  examples  of 
congenital  dislocations,  but  only  of  diastases,  the  separated  portions 
remaining  in  their  normal  positions  with  reference  to  each  other, 
except  that  they  are  not  prolonged  sufficiently  to  meet  in  the  median 
line. 

Guerin  declares,  however,  that  he  has  seen  congenital  displacement, 
or  overriding  of  the  iliac  bone  upon  the  sacrum,  accompanied  with 
coxo-femoral  dislocation  and  curvature  of  the  spine.  The  same  writer 
mentions  an  example,  in  a  foetal  monster,  of  diastasis  of  the  pubic 
bones,  and  of  the  sacro-iliac  symphysis,  accompanied  with  a  turning 
out  of  the  pubis  upon  the  external  face  of  the  ischium.^ 


§  6.  Congenital  Dislocations  of  the  Sternum.  j 

Seger  alone  has  reported  one  example  of  luxation  of  the  xiphoid 
cartilage  from  the  sternum. 

A  woman,  in  her  fifth  month  of  pregnancy,  fell  and  dislocated  her 
shoulder.  Just  four  months  after  this,  she  was  brought  to  bed  with 
an  infant,  well  formed,  except  that,  soon  after  it  was  born,  the  ensiform 
cartilage  was  observed  to  be  remarkably  movable,  especially  when  the 
child  hiccoughed,  to  which  it  was  very  subject.  The  cartilage  was 
separated  from  the  sternum  by  the  breadth  of  the  little  finger.  No 
treatment  was  employed;  the  cartilage  gradually  became  restored  to 
its  place,  and  in  about  one  year  it  was  firmly  united  to  the  sternum.^ 


§  T.  Congenital  Dislocations  of  the  Clavicle. 

Malgaigne  says  that  a  congenital  dislocation  at  the  sterno-clavicular 
articulation  has  never  been  observed ;  but  Guerin  declares  that  he  has 
established  the  existence  of  three  varieties,  namely: — 

1.  A  luxation  of  the  sternal  end  of  the  clavicle  inwards  and  for- 
wards ;  this  extremity  of  the  clavicle  lying  in  front  of  the  sternal 
fourchette.     In  illustration  of  which  he  presented  to  the  Academy  a 

'  Guerin,  op.  cit.,  p.  32. 

^  Seger,  Ephem.  Nat.  Curios.,  1677,  from  Malg.,  op.  cit.,  p.  410. 


CONGENITAL    DISLOCATIONS    OF    THE    SHOULDEE.         735 

plaster  cast  of  a  girl  eight  years  old,  in  whom  the  displacement  ex- 
isted upon  both  sides. 

2.  Inwards  and  upwards.  Observed  by  hira  in  a  girl  eight  years 
old  ;  but  which  displacement  took  place  only  when  the  arm  was  moved, 
and  through  the  contraction   of  the  sterno-cleido-mastoideus  muscle. 

8.  Backwards.  Of  which  he  presented  two  examples  in  the  cor- 
responding sides  of  a  foetal  monster. 

I  believe  I  have  already  referred  to  Fergusson's  case  of  dislocation 
of  the  sternal  end  of  the  clavicle  forwards,  which  occurred  daring 
birth.  The  end  rested  in  front  of  the  sternum,  and  could  be  pushed 
into  its  place  with  great  ease;  but  when  left  alone  it  immediately 
slipped  out  again.  Nothing  was  done,  a  new  joint  formed,  and  the  child 
afterwards  possessed  as  much  power  in  the  one  arm  as  in  the  other.' 

Guerin  says  that  he  has  seen  a  dislocation  upwards  and  outwards  at 
the  acromial  end  of  the  clavicle  in  a  foetus  of  three  months. 

In  regard  to  the  treatment  of  either  of  these  displacements  of  the 
clavicle,  we  need  only  remark  that  a  reduction  ought  to  be  attempted : 
and,  if  practicable,  without  much  confinement  of  the  little  patient,  it 
should  be  maintained  until  the  bones  have  become  fixed  in  their  natu- 
ral positions.  It  is  quite  probable  that  this  can  never  be  accomplished, 
at  least  perfectly;  but  it  will  nevertheless  be  proper  always  to  make 
the  attempt. 


§  8.  Congenital  Dislocations  of  the  Shoulder.     (  Upper  End  of  the 

Humerus.) 

Guerin  affirms  that  he  has  established  the  existence  of  three  varie- 
ties of  scapulo-humeral  dislocations,  namely: — 

1.  Dislocation  of  the  head  of  the  humerus  downwards;  of  which 
variety  he  presented  to  the  Academy  a  plaster  cast  taken  from  a  boy 
ten  years  old.  The  displacement  existed  in  both  arms,  but  much 
more  pronounced  in  the  right  than  in  the  left  arm.  It  was  due  wholly 
to  paralysis  of  the  muscles  about  the  joint,  and  to  elongation  of  the 
capsule. 

2.  Downwards  and  inwards;  complete  upon  one  side  and  incom- 
plete upon  the  other,  in  the  same  person.  The  head  of  each  humerus 
was  applied  against  the  ribs,  and  the  arms  maintained  in  an  abduction 
almost  horizontal,  under  the  influence  of  the  retraction  of  the  deltoid 
muscles.  "The  same  case,"  Guerin  remarks,  "has  been  confirmed  by 
Eoux." 

3.  Subluxation  upwards  and  outwards:  seen  on  both  sides  in  a 
foetal  monster,  which  was  offered  to  the  Academy  for  examination ; 
and  in  one  arm  of  a  young  man  fifteen  years  old,  of  which  Guerin 
presented  a  plaster  cast.  "  It  is  characterized  by  a  sliding  of  the  head 
of  the  humerus  in  the  direction  indicated;  this  sliding  being  favored 
by  a  corresponding  displacement  of  the  coracoid  and  acromion  pro- 
cesses."^ 

'  Fergusson,  System  of  Surg.,  4th  Amer.  ed.,  1853,  p.  203. 
^  Guerin,  op.  cit.,p.  30. 


736  CONGENITAL    DISLOCATIONS. 

Malgaigne,  who  regards  "  all  luxations  in  consequence  of  paralysis 
as  essentially  posterior  to  birth,"  will  not  admit  the  first  example  men- 
tioned by  Guerin ;  but,  as  we  stated  before,  the  objections  made  by 
Malgaigne  have  failed  to  convince  us  of  the  propriety  of  rejecting  all 
of  this  class  of  reported  examples.  Of  the  second  case,  mentioned 
by  Guerin  as  having  been  confirmed  by  Roux,  Malgaigne  declares 
that  he  has  consulted  Roux  upon  this  matter,  and  that  he  affirms  that 
"he  has  never  seen  a  congenital  luxation  of  the  shoulder." 

Robert  Smith  has  met  with  but  two  of  the  forms  of  congenital  luxa- 
tion of  the  humerus  described  by  Guerin,  namely,  that  in  which  the 
head  of  the  humerus  is  displaced  forwards,  and  that  in  which  it  is 
displaced  backwards.  Of  the  first  variety  he  has  seen  several 
examples. 

The  first  was  in  the  person  of  Alexander  Steele,  set.  29,  who 
presented  both  a  dislocation  of  the  head  of  the  humerus  under 
the  coracoid  process  of  the  left  scapula,  and  pes  equinus  in  the  foot 
of  the  left  leg.  The  muscles  of  the  arm  and  shoulder  upon  that  side 
were  feeble  and  greatly  atrophied.  The  humerus  was  shortened; 
its  head  being  of  the  natural  size  and  form,  Ijut  when  the  arm  hung 
by  the  side  it  dropped  so  far  from  its  socket  as  to  permit  the  thumb 
to  be  placed  between  the  head  and  the  acromion  process.  By  pressing 
the  humerus  forwards  the  finger  could  be  placed  in  the  outer  part  of 
the  glenoid  cavity ;  and,  although  the  head  could  be  moved  about 
thus  freely,  it  seemed  naturally  to  occupy  only  the  anterior  half  of  the 
glenoid  fossa. 

Robert  Smith's  second  example  of  subeoracoid  congenital  luxation 
was  presented  in  the  person  of  Mr.  H.,  get.  20,  the  condition  of  whose 
left  shoulder  resembled  almost  precisely  that  of  Mr.  Steele.  "  The 
deformity  had  existed  from  his  birth,  but  became  much  more  obvious 
and  striking  as  he  increased  in  age  and  stature." 

In  the  third  example  the  child  had  attained  nearly  the  age  of  one 
year  before  the  condition  of  the  limb  attracted  attention,  which  was 
then  excited,  not  by  the  deformity  of  the  shoulder  but  by  the  atrophied 
condition  of  the  muscles  of  the  arm.  The  child  had  never  complained 
of  pain  about  the  joint,  nor  had  he  ever  met  with  any  accident.  No 
doubt  this  also  was  an  example  of  paralysis,  and  it  is  not  improbable 
that  it  was  congenital,  but  the  evidence  upon  this  point  is  not  very 
conclusive.  When  seen  by  Mr.  Smith,  he  was  nine  years  old,  the 
shoulder  and  arm  presenting  the  same  appearance  as  in  the  other 
cases  mentioned. 

The  fourth  was  also  subeoracoid  and  symmetrical,  the  same  defor- 
mity existing  in  both  shoulders.  This  was  in  the  person  of  a  female, 
set.  29,  who  had  been  for  many  years  a  patient  in  a  lunatic  asylum, 
and  who  died  of  chronic  inflammation  of  the  meninges  of  the  brain. 

Mr.  Smith,  who  himself  made  the  autopsy,  first  noticed  the  condi- 
tion of  the  left  shoulder.  The  muscles  were  atrophied;  the  head  of 
the  humerus  could  be  felt  lying  under  the  coracoid  process ;  the  elbow 
projected  from  the  side,  but  could  be  readily  brought  into  contact 
with  it.     The  right  shoulder  presented  the  same  appearance,  but  the 


I 


CONGENITAL    DISLOCATIONS    OF    THE    SHOULDER.         737 

deformity  was  somewhat  less,  and  the  head  of  the  humerus  was  not  so 
directly  underneath  the  coracoid  process. 

From  the  external  appearances  presented  by  the  two  shoulders,  Mr. 
Smith  did  not  doubt  that  these  deviations  from  the  natural  state  of  the 
parts  were  not  the  result  of  violence. 

Proceeding  to  remove  the  soft  parts  upon  the  left  side,  scarcely  any 
trace  was  found  of  a  glenoid  cavity  in  its  natural  situation,  but  imme- 
diately underneath  the  coracoid  process,  upon  the  costal  surface  of  the 
scapula,  was  formed  an  oblong  socket  completely  surrounded  by  a 
capsular  ligament,  which  ligament  included  also  that  small  portion  of 
the  original  socket  which  remained.  The  head  of  the  humerus  was 
changed  in  form,  being  oval,  and  fitted,  in  some  measure,  to  both  the 
old  and  new  sockets  upon  which  it  seemed  to  rest  alternately. 

Upon  the  right  side,  although  the  condition  of  the  bones  was  some- 
what different,  the  characteristic  features  of  the  deformity  were  simi- 
lar. 

Malgaigne,  who  quotes  Mr.  Smith  as  saying  that  these  dislocations 
must  have  been  congenital,  and  for  no  other  reason  than  because  they 
were  symmetrical,  has  scarcely  done  this  author  justice.  Says  Mr. 
Smith :  "  The  position  of  the  glenoid  cavity,  the  remarkable  form  of  the 
head  of  the  humerus,  the  presence  of  a  perfect  glenoid  ligament,  the 
absence  of  any  trace  of  disease,  and  the  existence  of  the  deformity 
upon  each  side,  all  indicate  the  original  nature  of  the  malformation." 

The  only  example  of  backward  luxation  seen  by  Smith  was  also 
symmetrical,  and  seems  to  be  equally  well  authenticated.  This  was 
in  the  person  of  a  woman  named  Doyle,  £et.  42,  a  lunatic  also,  who 
died  Feb.  8,  1839,  in  Dublin.  She  had  been  a  patient  in  the  lunatic 
asylum  fifteen  years,  and  was  subject  to  severe  epileptic  convulsions, 
which  ultimately  proved  fatal. 

Mr.  Smith  made  the  autopsy  on  the  day  following  her  death.  The 
convolutions  of  the  brain  were  small  and  atrophied,  as  is  frequently 
observed  in  idiots. 

The  two  shoulders  resembled  each  other  so  perfectly,  both  in  ex- 
ternal appearance  and  in  their  anatomy,  that  Mr.  Smith  has  only  found 
it  necessary  to  describe  particularly  the  condition  of  one. 

The  coracoid  process  was  remarkably  prominent,  but  the  acromion 
was  not  so  prominent  as  in  accidental  dislocations  of  the  shoulder. 
The  head  of  the  humerus  could  be  seen  and  felt  distinctly  moving 
with  the  shaft,  upon  the  dorsal  surface  of  the  scapula.  On  removing 
the  integuments,  muscles,  &c.,  no  trace  of  a  glenoid  cavity  was  found 
in  its  natural  situation;  but  upon  the  external  surface  of  the  neck 
of  the  scapula  was  a  well-formed  socket,  which  received  the  head  of 
the  humerus.  This  socket  was  covered  with  cartilage  of  incrustation, 
and  surrounded  by  a  perfect  capsule.  The  tendon  of  the  biceps  arose 
from  the  top  and  internal  margin  of  the  socket.  The  form  of  the 
acromion  process  was  changed  ;  the  scapula  smaller  than  natural ;  the 
head  of  the  humerus  irregularly  oval,  its  anterior  half  alone  being 
in  contact  with  the  glenoid'cavity ;  the  great  tubercle  natural,  but  the 
lesser  was  elongated  and  curved,  forming  a  process  of  an  inch  in 
47 


738  CONGENITAL    DISLOCATIONS. 

length,  around  the  base  of  which  the  tendon  of  the  biceps  muscle 
played.^ 

Gaillard  relates  the  case  of  a  female  child,  upon  whom  the  left  arm 
was  discovered  to  be  deformed  a  few  days  after  birth,  and  the  elbow 
separated  from  the  side.  Later,  the  arm  was  found  to  be  nearly  im- 
movable, and  only  at  the  end  of  four  years  was  the  dislocation  recog- 
nized;  but  no  attempt  at  reduction  was  then  made.  \Yhen  sixteen 
years  old,  she  was  seen  by  Gaillard,  who  found  the  head  of  the  humerus 
in  the  infra-spinous  fossa.  The  scapula,  clavicle,  and  arm  were  pre- 
ternaturally  small;  the  forearm,  although  well  developed,  could  not 
be  completely  extended  nor  supinated. 

Despite  tliese  unfavorable  circumstances,  Gaillard  determined  to 
make  an  attempt  to  accomplish  the  reduction.  Four  times  in  the  space 
of  eight  days  he  submitted  the  arms  to  extension  made  at  right  angles 
with  the  body,  by  means  of  sixteen  pound  weights,  the  extension  being 
continued  from  twenty  to  twenty-five  minutes,  and  occasionally  his 
own  exertions  being  added  to  the  weights.  On  the  fourth  attempt, 
the  head  of  the  bone  was  drawn  gradually  forwards,  and  by  a  rotatory 
motion  it  was  finally  made  to  slip  into  its  socket ;  but  it  became  im- 
mediately displaced.  The  next  day  Gaillard  reduced  it  anew,  and 
retained  it  in  place  one  hour.  Six  days  later  it  was  again  reduced,  and, 
by  the  aid  of  bandages,  permanently  retained  in  place.  The  slight 
pain  and  swelling  which  followed  soon  disappeared ;  and,  by  the  aid 
of  c'areful  exercise,  at  the  end  of  two  years  the  arm  had  increased  in 
length,  and  the  patient  could  use  the  arm  and  hand  so  much  better 
than  before,  as  to  encourage  a  hope  that  the  recovery  would  be  com- 
plete.^ 

Aristide  Eodrigue,  of  Hollidaysburg,  Penn.,  in  a  letter  to  the 
editor  of  the  American  Journal  of  Medical  Sciences,  gives  the  following 
brief  account  of  a  case  of  intra-uterine  dislocation  of  the  shoulder, 
complicated  with  a  fracture  of  the  forearm. 

"The  woman  when  about  four  months  gone  with  child,  fell  on  her 
left  side,  striking  a  board,  and  felt  herself  much  hurt  at  the  time:  at 
the  full  period  she  was  delivered  of  a  full-grown  large  boy  with  the 
following  deformity:  dislocation  of  the  humerus  into  the  axilla;  frac- 
ture of  both  bones  of  forearm  of  left  side,  lower  third.  Dislocation 
could  not  be  reduced;  union  of  the  bones  of  the  forearm  by  ossific 
matter  complete;  bones  passing  each  other,  and  hand  at  an  angle  of 
about  40°;  the  child  did  well  otherwise;  now,  four  years  old,  strong 
and  healthy  ;  humerus  has  grown  nearly  apace  with  the  other ;  forearm 
has  not,  and  remains  short  and  deformed  as  at  birth ;  the  hand  is  of 
the  same  size  with  that  of  the  sound  side."'' 

'  Robert  Smith,  op.  cit. 

2  Gaillard,  Mem.  de  I'Acad.  de  Med.,  1841,  from  Malg.,  p.  569. 

3  Rodrigue,  loc.  cit.,  Jan.  1854,  p.  272. 


DISLOCATIONS    OF    THE    HEAD    OF    THE    EADIUS.  739 


§  9.  Congenital  Dislocations  of  the  Radius  and  Ulna  Backwards. 

It  is  not  uncommon  to  meet  with  examples  of  a  slight  subluxation 
backwards  of  these  bones  in  feeble  and  newly-born  infants;  which 
condition  is  probably  due  to  a  relaxation  and  elongation  of  the  capsule. 
It  is  characterized  by  a  preternatural  mobility  of  the  joint,  and  espe- 
cially by  the  circumstance  that  the  limb  is  capable  of  abnormal  ex- 
tension, or  flexion  backwards,  as  it  is  sometimes  called.  Guerin  has 
seen  this  condition  more  advanced,  the  bones  of  the  forearm  having 
actually  overlapped  somewhat  upon  the  lower  end  of  the  humerus,  so 
that  the  articular  surface  of  this  latter,  presented  itself  in  the  fold  of 
the  elbow.  This  was  especially  observed  in  a  girl  of  fourteen  and  a 
boy  of  thirteen  years,  and  also  in  the  two  arms  of  a  foetal  monster.' 

Chaussier  relates  that  a  young  woman  at  the  commencement  of  the 
ninth  month  of  pregnancy,  perceived  suddenly  movements  of  the 
foetus  so  violent  that  she  almost  lost  her  consciousness.  These  move- 
ments were  repeated  three  times  in  the  space  of  six  minutes,  after 
which  everything  returned  to  its  natural  order,  and  the  accouchement 
took  place  naturally  and  at  the  usual  term.  The  infant  was  pale  and 
feeble,  and  presented  a  complete  backward  luxation  of  the  radius  and 
ulna.^ 

§  10.  Congenital  Dislocations  or  the  Head  of  the  Radius. 

Examples  of  this  luxation  have  been  reported  by  Dupuytren,  Cru- 
veilhier,  Sandifort,  Adams,  Dubois,  Yerneuil,  Deville,  Eobert  Smith, 
and  Guerin,  most  of  which  were  in  the  direction  backwards,  some 
outwards,  but  only  one  of  them  forwards;  some  were  double,  the  same 
deformity  being  presented  in  both  arms,  and  others  were  single.  In 
a  few  examples  the  dislocations  were  complicated  with  a  consolidation 
of  the  radius  to  the  ulna,  and  in  others  with  a  deficiency  of  the  ulna 
or  with  some  deformity  indicating  its  congenital  origin. 

Of  the  symmetrical  or  double  dislocation  backwards  Dupuytren 
furnishes  the  following  example,  presented  to  him  in  1880,  by  M. 
Loir :  "  The  abnormal  position  which  the  head  of  either  radius  had 
assumed  was  at  the  back  part  of  the  lower  extremity  of  the  humerus, 
beyond  which  it  extended  for  the  space  of  at  least  an  inch.  This 
disposition  of  parts  was  absolutely  identical  on  the  two  sides,  and  had 
all  the  characters  of  a  congenital  affection."^ 

In  the  example  of  outward  luxation,  mentioned  by  Deville,  there 
was  an  almost  complete  absence  of  the  ulna,  the  head  of  the  radius 
mounting  upwards  more  than  three  centimetres  above  the  level  of  the 
articulation.'* 

Gu6rin,  who  has  described  the  only  example  of  a  forward  luxation, 
says  it  was  observed  by  him  in  a  girl  of  seven  years,  and  that  it  was 

'  Guerin,  op.  cit.,  p.  31.  ^  Chaussier,  from  Malgaigne,  op.  cit.,  t.  ii.  p.  268. 

^  Dupuytren,  Injuries  and  Dis.  of  Bones,  p.  117. 
<  Deville,  Bulletins  de  la  Soc.  Anat.,  1849,  p.  15.3. 


740  CONGENITAL    DISLOCATIONS. 

symmetrical.     The  two  radii  lay  in  front  of  the  humeri  near  the  coro-    j 
nary  fossettes.^  j 

§  11.  Congenital  Dislocations  of  the  Whist. 

Gu^rin  thinks  he  has  seen  three  forms  of  congenital  luxation  of  the 
wrist.  B'irst,  a  dislocation  forwards  characterized  by  a  sliding  of  the 
wrist  before  the  bones  of  the  forearm,  and  by  the  projection  posteriorly 
of  the  lower  ends  of  the  radius  and  ulna;  seen  in  an  infant  of  six 
months,  and  in  two  adults.  Second,  backwards  and  upwards;  seen 
in  a  child  of  six  years,  and  accompanied  with  an  incomplete  paralysis 
of  all  the  muscles  of  the  forearm  and  hand.  Third,  backwards  and 
outwards ;  in  a  girl  of  fourteen  years,  accompanied  with  incomplete 
paralysis.^ 

Guerin  has  also  seen  three  examples  of  dislocation  outwards  in 
foetal  monsters,  and  one  of  dislocation  inwards,  as  the  result  of  arrest 
of  development. 

Robert  Smith  believes  that  the  case  of  simple  dislocation  of  the 
wrist  or  of  the  carpus  forwards,  mentioned  by  Cruveilhier  in  his  Ana- 
tomie  Pa.thologique,  was  an  example  of  congenital  luxation ;  and  he 
relates  two  other  cases  equally  remarkable  which  came  under  his  own 
observation.  One  was  in  the  person  of  Deborah  O'Neil,  a  lunatic  and 
epileptic,  who  died  when  thirty-six  years  old.  Both  upper  extremities 
were  deformed  from  birth ;  the  right  presenting  an  example  of  dislo- 
cation of  the  carpus  forwards,  and  the  left  of  dislocation  of  the  carpus 
backwards.  The  dissection  showed  that  there  had  been  an  arrest  of 
development,  especially  in  the  bones  of  the  forearm  and  carpus.  The 
second  was  in  the  person  of  a  young  woman  who  died  of  phthisis  in 
the  Richmond  Hospital ;  the  right  wrist  presenting  an  example  of 
congenital  dislocation  of  the  carpus  forwards  from  arrest  of  develop- 
ment also.'' 

Marrigues  describes  a  very  singular  congenital  displacement  which 
he  found  upon  a  newly-born  infant.  The  radius  and  ulna  were  widely 
separated  below,  and  in  the  interspace  was  lodged  the  whole  of  the 
first  range  of  the  carpal  bones;  the  hand  being  strongly  turned  in- 
wards.'' 

§  12.  Congenital  Dislocations  of  the  Fingers. 

Chaussier  found  in  a  foetus  the  last  three  fingers  of  the  left  hand 
dislocated  at  the  metacarpo-phalangeal  articulation.  The  thighs,  knees, 
and  feet  were  also  dislocated.* 

A.  Berard  speaks  of  an  incurvation  backwards  of  the  last  two  pha- 
langes of  the  fingers  as  having  been  occasionally  seen  in  newly-born 
children  of  the  female  sex;  and.  Malgaigne  adds  that  he  has  himself 


J  Guerin,  op.  cit.,  p.  31.  ^  Ibid.,  p.  717. 

3  R.  Smith,  op.  cit.,  pp.  238,  251. 

*  Marrigues,  Malgaigne,  from  Journ.  de  Med.,  1775,  t.  ii.  p.  31. 

*  Chaussier,  Malgaigne,  op.  cit.,  t.  ii.  p.  751. 


I 


CONGBlSriTAL    DISLOCATIOlSrS    OF    THE    HIP.  741 

seen  a  woman  who  had,  from  birth,  all  the  phalangettes  carried  back- 
wards to  an  angle  of  135°,  leaving  the  heads  of  the  phalanges  project- 
ing forwards  under  the  skin.^ 

Eobert  has  seen,  in  a  girl  six  years  old,  a  congenital  lateral  luxation 
of  the  phalangette  of  the  index  finger,  which  was  inclined  outwards  at 
an  obtuse  angle.  The  external  condyle  of  the  lower  extremity  of  the 
proximal  phalanx  was  slightly  atrophied,  and  the  internal  presented  a 
corresponding  projection.  Eobert  cut  the  internal  lateral  ligament  by 
a  subcutaneous  incision,  but  without  any  favorable  result,^ 


§  13.  Congenital  Dislocations  op  the  Hip. 

Dopuytren  thought  that  double  dislocations  of  the  hip-joint,  as 
congenital  accidents,  were  more  common  than  single  dislocations,  but 
in  the  experience  of  Pravaz  the  rule  has  been  reversed,  he  having  met 
with  but  four  double  dislocations  in  a  total  of  nineteen. 

Congenital  dislocations  of  the  femur  have  been  noticed  much  oftener 
in  females  than  in  males.  Of  forty-five  examples  mentioned  by  Du- 
puytren  and  Pravaz,  only  seven  or  eight  were  males. 

They  may  be  complete  or  incomplete.  Of  the  complete  luxations, 
four  varieties  have  been  noticed. 

Upwards  and  backwards,  upon  the  dorsum  ilii.  This  variety  is  by 
far  the  most  common. 

Upwards  and  forwards;  the  head  of  the  femur  resting  upon  the 
eminentia  ilio-pectinea. 

Downwards  and  forwards  into  the  foramen  thyroideum ;  of  which 
variety  Chaussier  alone  mentions  one  example;  but  Delpech  found  in 
an  infant,  born  paralytic,  the  head  of  the  femur  lodged  habitually  near 
the  foramen  thyroideum. 

Directly  upwards;  seen  by  Gu^rin,  Pravaz,  and  others;  the  head 
of  the  femur  being  placed  immediately  without  the  anterior  inferior 
spinous  process  of  the  ilium. 

Guerin  has  observed,  moreover,  a  single  variety  of  subluxation ; 
characterized  by  the  incomplete  displacement  of  the  head  of  the  femur 
in  the  direction  upwards  and  backwards,  so  that  it  rested  upon  the 
edge  of  the  cotyloid  cavity  :  "  Observed  often  in  newly-born  children, 
and  with  those"in  whom,  the  muscular  dislocations  are  effected  sponta- 
neously after  birth." 

Both  Delpech  and  Guerin  have  called  attention  to  two  varieties  of 
what  the  latter  terms,  pseudo-luxations ;  of  which  the  first  simulates 
a  dislocation  upwards  and  backwards,  and  the  second  a  dislocation 
downwards  and  forwards.  In  these  examples,  the  extreme  adduction 
or  abduction  of  the  thighs  might  lead  to  a  belief  that  the  bones  were 
dislocated,  when  in  fact  the  abnormal  position  of  the  limbs  are  due 
only  to  muscular  contraction,  without  actual  articular  displacement. 

In  the  remarks  which  follow,  we  shall  have  special  reference  to  that 
form  of  congenital  dislocation  of  the  femur  in  which  the  head  of  the 

'  Berard,  Malgaigne,  op.  cit.,  p.  773.  ^  Robert,  from  Malg.,  op.  cit.,  p.  773. 


742  CONGENITAL    DISLOCATIONS. 

bone  rests  upon  the  dorsum  ilii,  as  being  that  which  will  be  presented 
in  a  vast  majority  of  cases,  and  which,  characterized  by  the  same 
general  phenomena,  may  be  regarded  as  typical  of  all  the  others. 

Symptomatology. — First.  When  the  dislocation  is  double. 

In  these  examples  the  deformity  is  often  found  to  be  symmetrical ; 
the  opposite  limbs  being  of  precisely  the  same  length,  and  in  the  same 
relative  positions ;  a  circumstance  which,  when  it  exists,  may  render 
the  diagnosis  more  difficult,  or  may  cause  it  to  be  for  a  long  time 
entirely  overlooked.  It  is  in  such  cases  especially,  that  the  deformity 
is  not  usually  discovered  until  the  child  begins  to  walk. 

The  first  circumstance  which  would  naturally  arrest  our  attention, 
if  the  person  who  is  the  subject  of  this. double  dislocation  is  stripped 
and  placed  erect  before  us,  is  the  great  apparent  length  of  the  arms 
and  of  the  body  in  comparison  with  the  lower  extremities.  We  may 
next  observe  that  the  great  trochanters  are  carried  upwards  and  back- 
wards, so  as  to  make  a  remarkable  projection  in  this  direction ;  the 
lumbar  portion  of  the  spinal  column  is  thrown  very  much  forwards, 
and  the  dorsal  portion  backwards.  The  thighs  incline  inwards,  so  as 
almost  to  cross  each  other;  the  whole  of  the  lower  extremities  are 
imperfectly  developed  and  feeble,  the  toes  are  generally  pointed  di- 
rectly forwards,  or  they  may  be  noticed  to  turn  inwards. 

When  the  person  stands,  and  his  limbs  are  not  in  motion,  the  heel 
is  usually  brought  down  fairly  to  the  floor;  but  in  walking,  and 
especially  in  the  attempt  to  run,  he  touches  only  the  balls  and  toes  of 
his  feet.  "  When  they  are  about  to  walk,"  says  Pravaz,  "  we  see  them 
lift  themselves  upon  the  points  of  the  feet,  to  incline  the  superior  part 
of  the  trunk  toward  the  member  which  is  about  to  support  the  weight 
of  the  body,  and  to  lift  the  other  from  the  ground  with  an  effort,  in 
order  to  carry  it  forwards.  At  this  moment  one  of  the  trochanters, 
that  which  corresponds  to  the  column  of  sustentation,  appears  to 
approach  the  iliac  crest  more  nearly  than  when  the  patient  is  standing 
upon  his  two  feet."  In  consequence  of  which  mobility  of  the  thigh- 
bones, the  patient  assumes  a  peculiar  waddling  gait,  which  is  not  only 
ungraceful  but  exceedingly  fatiguing. 

The  difficulty  of  progression  is,  however,  very  variable  in  different 
persons.  Sometimes  the  patient  requires  no  aid  whatever,  and  at 
other  times  he  cannot  walk  without  assistance.  Generally  it  increases 
with  age.  It  is  especially  deserving  of  notice  that  in  rapid  progressioii 
the  mobility  of  the  heads  of  the  femurs  is  appreciably  less  than  in 
slow  progression,  which  is  explained  by  the  more  constant  and  vigor- 
ous contraction  of  the  muscles  about  the  joint,  when  the  motions  of 
the  limb  are  rapid. 

In  the  recumbent  posture,  the  thighs  may  be  drawn  down  easily  to 
almost  their  natural  positions.  The  only  exception  to  this  rule,  accord- 
ing to  Carnochan,  "is  when  the  head  of  the  femur  has  escaped  from 
the  natural  capsule  in  which  it  was  originally  inclosed,  and  a  new 
socket  has  been  formed  upon  the  dorsum  of  the  ilium." 

Abduction  is  performed  with  difficulty ;  adduction  and  rotation, 
especially  inwards,  being  less  restricted. 

Second.  When  the  dislocation  is  only  upon  one  side. 


CONGENITAL    DISLOCATIONS    OF    THE    HIP.  743 

In  these  cases  the  symptoms  are  essentially  the  same  as  in  the  double 
dislocation  ;  with  only  such  slight  differences  and  peculiarities  as  would 
naturally  suggest  themselves  to  the  surgeon,  and  which  will  not,  there- 
fore, demand  from  us  a  special  consideration. 

Pathology.— The  head  of  the  femur  is  sometimes  merely  changed  in 
form  and  consistence,  the  neck  also  undergoing  corresponding  altera- 
tions in  its  size,  form,  direction,  &c.;  at  other  times  the  head  is  absent 
altogether,  and  with  it  a  considerable  portion,  or  the  whole  of  the  neck 
has  disappeared. 

The  pelvic  bones  are  usually  more  or  less  deformed.  The  acetabu- 
lum may  be  entirely  deficient,  or  it  may  present  itself  as  an  irregular 
bony  protuberance,  without  cartilage,  fibro-cartilage,  or  ligaments. 
Sometimes  it  exists  as  an  oval  or  triangular  cavity,  which  is  expanded 
at  its  superior  and  posterior  margin  into  a  distinct  fossa,  where  the 
head  of  the  femur,  descending  from  the  dorsum  ilii,  occasionally  rests 
A  new  cavity  is  formed  usually  upon  the  side  of  the  pelvis,  which  is 
shallow  and  without  an  elevated  margin,  or  it  may  be  deeper,  and  more 
complete  in  its  construction,  by  the  addition  of  an  osseous  border.  In 
either  case,  the  new  socket  is  often  lined  with  a  true  periosteum  and 
synovial  membrane ;  but  not  unfrequently  it  is  unprotected  by  any 
soft  tissue,  the  surface  being  hard  and  polished  like  ivory. 

The  head  of  the  femur,  having  escaped  from  its  original  capsule, 
through  a  button-like  opening,  rests  in  this  socket  constantly.  In  still 
other  examples  the  head  of  the  femur  remains  within  its  capsule,  and  may 
be  observed  to  play  backwards  and  forwards  between  the  two  sockets ; 
or  the  head  and  neck  being  absorbed,  and  the  capsule  remaining  entire, 
the  latter  is  converted  into  a  long  narrow  sac,  somewhat  contracted  in 
its  centre,  or  finally  into  a  firm  ligamentous  cord,  which,  being  attached 
to  the  stunted  upper  extremity  of  the  femur,  limits  its  motions  in  the 
direction  of  the  crest  of  the  ilium.  In  this  case  no  new  socket  is 
formed. 

A  portion  of  the  pelvi-femoral  muscles  are  contracted,  in  consequence 
of  an  approximation  of  their  points  of  origin  and  insertion,  and  re- 
maining in  a  state  of  comparative,  if  not  absolute,  inertia,  they  become 
atrophied,  or  pass  into  a  condition  of  fatty  degeneration,  while  other 
muscles,  in  consequence  of  the  increased  labor  which  they  have  to 
perform,  become  hypertrophied,  or  degenerate  into  a  fibrous  tissue. 

Treatment. — Says  Dupuytren:  "  Of  what  possible  utility  can  it  be  to 
practice  extension  of  the  lower  extremities  in  these  cases,  even  sup- 
posing the  limbs  could  be  thus  brought  to  their  natural  length?  Is 
it  not  evident  that  the  head  of  the  femur,  finding  no  cavity  fitted  to 
receive  and  hold  it,  would,  when  abandoned  to  itself,  resume  its  former 
abnormal  position  ?  There  is  something  more  rational  and  feasible 
in  adopting  a  palliative  course  of  treatment.  When  we  call  to  mind 
the  natural  proneness  which  the  heads  of  thigh-bones  have  to  ascend 
to  the  external  iliac  fossas,  and  that  this  tendency  is  partly  due  to  the 
superincumbent  weight  of  the  body,  and  in  part  to  muscular  action,  a 
just  conception  may  be  formed  of  the  indications  on  which  the  employ- 
ment of  palliative  remedies  should  be  founded.  The  object  should  be 
to  relieve  the  lower  limbs  of  the  superincumbent  weight,  on  ihe  one 


744:  CONGENITAL    DISLOCATIONS. 

hand,  and  on  the  other  to  moderate  the  muscular  action.  Both  of 
these  indications  are  in  part  fulfilled  by  repose ;  and  the  attitude  most 
conducive  to  this  effect  is  the  sitting  posture,  in  which  the  weight  of 
the  upper  part  of  the  body  is  not  transmitted  to  the  lower  extremities, 
but  is  centred  in  the  tuberosities  of  the  ischia.  Therefore,  laboring 
persons  afflicted  with  this  infirmity  should  be  recommended  to  adopt 
a  sedentary  occupation,  as  a  calling  which  requires  much  standing  and 
walking  about  would  dangerously  aggravate  their  deformity.  Yet 
one  would  scarcely  be  willing  to  condemn  such  individuals  to  perpetual 
repose ;  and  to  avoid  this  it  is  necessary  to  discover  some  means  for 
diminishing  the  inconveniences  which  attend  the  upright  posture,  the 
act  of  walking,  and  other  exercises.  Experience  has  taught  me  hitherto 
but  two  methods  of  obtaining  this  important  object:  the  first  consists 
in  the  daily  employment  of  a  perfectly  cold  bath,  in  which  all  the 
body  should  be  immersed  for  the  space  of  three  or  four  minutes,  the 
head  being  protected  by  an  oiled-silk  cap ;  the  water  may  be  fresh  or 
salt;  and  the  only  precautions  necessary  to  take  are  to  avoid  bathing 
when  the  body  is  in  a  state  of  perspiration,  or  when  the  catamenial 
discharge  is  present.  These  baths  have  a  local,  as  well  as  general, 
tonic  efi'ect.  The  second  method  consists  in  the  constant  use,  at  least 
during  the  day,  of  a  belt,  which  embraces  the  pelvis,  fitting  closely 
over  the  great  trochanters,  and  keeping  them  at  a  constant  height,  so 
as  to  bind  the  parts  together,  and  prevent  that  continual  unsteadiness 
of  the  body  which  results  from  the  loose  connections  of  the  heads  of 
the  thigh-bones.  For  the  proper  fulfilment  of  these  indications,  cer- 
tain precautions  are  necessary  in  the  construction  of  this  cincture;  in 
the  first  place,  it  should  occupy  the  narrow  interval  between  the  crest 
of  the  ilium  and  great  trochanters,  completely  filling  this  space,  and 
therefore  being  about  three  or  four  fingers'  breadth,  according  to  the 
age  and  size  of  the  patient.  It  should  further  be  well  padded  with 
wool  or  cotton,  and  covered  with  doe-skin,  so  that  it  may  not  abrade 
the  parts  to  which  it  is  applied ;  and  there  should  be  a  piece  let  in  on 
either  side,  so  as  to  receive  and  support  the  trochanters  without  entirely 
covering  them ;  it  should  be  buckled  behind,  and  padded  straps  be 
carried  under  the  thigh,  and  across  the  tuberosity  of  the  ischium,  on 
either  side,  to  prevent  the  zone  from  slipping  up.  I  do  not  mean  to 
assert  that  I  have  ever  succeeded  in  completely  getting  rid  of  the 
inconveniences  of  congenital  dislocations  of  the  thigh-bones,  but  I  have 
prevented  their  increasing,  and  have  rendered  supportable  what  I  could 
not  cure.  The  testimony  of  some  patients  to  the  value  of  this  treat- 
ment has  been  of  a  most  unequivocal  character ;  for,  being  worried 
by  the  pressure  of  the  belt,  they  have  laid  it  aside,  but  have  speedily 
restored  it  again,  as  they  found  that  without  it  they  had  neither  a 
sense  of  firmness  in  the  hip,  nor  confidence  in  walking." 

In  relation  to  which  opinions  the  same  excellent  writer  subsequently 
made  the  following  candid  admissions:  "I  at  first  thought  that  no 
benefit  would  be  derived  in  these  cases  from  the  employment  of  con- 
tinual traction  on  the  lower  extremities,  for  reasons  already  stated; 
but  the  experiments  of  MM.  Lafond  and  Duval  tend  to  throw  some 
doubt  on   the  correctness  of  this  conclusion.     These  distino;uished 


CONGENITAL    DISLOCATIONS    OF    THE    HIP.  745 

practitioners  tested  the  influence  of  extension,  in  their  orthopasdic 
institution,  on  a  child  eight  or  nine  years  of  age,  who  was  the  subject 
of  double  congenital  dislocation  of  the  hip ;  after  the  uninterrupted 
employment  of  this  treatment  for  some  weeks,  I  satisfied  myself  that 
the  limbs  had  resumed  their  natural  length  and  direction ;  but  I  was 
not  a  little  astonished  to  find  that,  after  extension  had  been  persisted 
in  for  three  or  four  mouths  continuously,  the  greater  part  of  the  bene- 
ficial results  remained  for  several  weeks  undiminished.  It  would  be 
idle,  it  is  true,  to  generalize  on  this  single  case;  but  as  an  isolated 
example  of  the  utility  of  extension  it  is  interesting,  and  it  may  be  the 
forerunner  of  more  important  results.''^ 

Since  which  time  Humbert  and  Jacquier,  who,  as  well  as  Duval  and 
Lafond,  confined  themselves  to  the  treatment  of  deformities,  claim  to 
have  met  with  equal  success  in  the  management  of  these  cases  by 
extension  alone ;  and,  still  more  lately,  Guerin,  of  Paris,  and  Pravas, 
of  Lyons,  by  the  adoption  of  the  same  general  principle  more  or  less 
modified,  have  added  new  triumphs,  and  greatly  enlarged  its  appli- 
cation. 

The  means  recommended  and  practiced  by  Guerin,  are:  first,  pre- 
paratory extension  destined  to  elongate  the  muscles  as  much  as  possi- 
ble ;  second,  subcutaneous  section  of  the  muscles  which  mechanical 
extension  has  not  sufficiently  elongated ;  third,  extension  of  the  liga- 
ments, and  even,  if  extension  does  not  suffice,  their  subcutaneous 
section ;  fourth,  manoeuvres  destined  to  effect  reduction ;  fifth,  treat- 
ment designed  to  consolidate  the  reduction,  and  consisting  in  the 
application  of  the  apparatus  proper  to  maintain  the  extension  and 
separation  of  the  divided  tissues,  and  to  retain  the  head  of  the  femur 
in  its  place;  finally,  in  the  gradual  execution  of  movements  proper  to 
complete  the  coaptation  of  the  surfaces,  and  to  establish  little  by  little 
the  physiological  movements  of  the  joint. 

Other  surgeons  have  confined  their  efforts  to  the  reduction  of  the 
dislocation,  and  they  have,  consequently  abandoned  all  those  cases  in 
which,  owing  to  the  complete  absence  of  the  natural  socket,  or  to 
the  want  of  sufficient  mobility  in  the  limb,  the  reduction  was  deemed 
impossible;  but  Guerin  has  gone  a  step  farther,  and  has  sought  to 
establish  a  new  socket  upon  some  point  of  the  pelvic  bones  as  near  as 
possible  to  its  natural  articular  fossa.  "  The  means  which  I  adopt," 
says  Guerin,  "are  based  upon  a  recognition  of  the  processes  which 
nature  employs  for  the  attainment  of  the  same  purpose,  and  of  which 
mine  are  but"an  imitation.  I  have  shown  that  the  essential  condition 
of  the  formation  of  artificial  cavities  is  perforation  of  the  articular 
capsule,  and  the  placing  in  contact  of  the  luxated  extremity  with  an 
osseous  surface,  and  that  the  condition  of  the  maintenance  of  this 
abnormal  rapport  is  the  intimate  adherence  of  the  borders  of  the  rent 
with  the  circumference  of  the  new  cavity.  Now  it  appeared  to  me 
that  art  could  realize,  in  all  points,  the  conditions  which  preside  at  the 
spontaneous  formation  of  artificial  joints.  To  this  end  I  commence  by 
practicing  under  the  skin,  and  at  the  point  corresponding  to  that  where 

'  Dupuytren,  op.  cit.,  pp.  176-8. 


746  CONGENITAL    DISLOCATIONS. 

it  is  most  convenient  to  fix  the  luxated  extremity,  scarifications  of  the 
capsule,  down  to  the  bone  to  which  it  is  attached.  By  this  means  the 
dislocated  extremity  is  placed  in  immediate  contact  with  the  bony 
surface  upon  which  it  reposes.  It  makes  upon  this  point  a  beginning 
of  the  work  of  organization  resulting  from  the  adhesion  and  fusion  of 
the  scarified  points  with  the  corresponding  points  of  this  surface. 
Then,  in  order  to  circumscribe  and  imprison  the  luxated  extremity, 
in  this  place  of  election,  I  practice  all  about  deep  scarifications,  which 
tend  to  excite  the  same  work  of  organization  and  to  establish  fibro- 
cellular  adhesions  between  the  incised  borders  of  the  capsule  and  the 
contiguous  bony  surfaces. 

"Finally,  when  the  fibro-cellular  adhesions  are  supposed  to  be  suf- 
ficiently solid  to  resist  the  movements  of  the  new  articuhition,  I  pro- 
voke, little  by  little,  the  development  of  the  cavity  destined  to  embrace 
the  luxated  extremity  by  the  means  which  nature  herself  employs  in 
analogous  circum.stances;  that  is  to  say,  by  circumscribed  and  frequent 
movements  of  this  articulation."^ 

The  treatment  ought  to  be  commenced  as  early  as  possible,  no  ex- 
amples of  success  having  been  recorded  in  persons  over  fifteen  years 
of  age;  while  the  youngest  child  whose  treatment  is  reported  as  suc- 
cessful was  three  years  of  age. 

For  the  purpose  of  making  the  requisite  extension,  and  of  main- 
taining the  bone  in  place,  Pravaz  (who  does  not,  however,  adopt 
Gu^rin's  practice  of  establishing  for  the  head  of  the  bone  a  new  socket, 
but  only  seeks  to  reduce  and  maintain  it  in  its  old  socket)  has  invent- 
ed several  forms  of  apparatus  adapted  to  the  different  stages  of  pro- 
gress in  the  treatment.  Heine,  of  Oannstadt,  Guerin,  and  others  have 
also  suggested  special  contrivances  for  the  same  purpose;  but  no  sur- 
geon who  understands  fully  the  principle  upon  which  the  cure  is 
supposed  to  be  accomplished,  will  be  at  a  loss  for  apparatus  suitable 
for  making  the  necessary  extension,  or  for  maintaining  the  reduction 
when  once  it  has  been  effected. 

The  length  of  time  required  for  the  completion  of  a  cure,  where  a 
cure  is  possible,  must  vary  according  to  the  age  and  health  of  the 
patient,  and  according  to  the  pathological  condition  of  the  joint,  and 
may  be  found  to  extend  from  a  few  months  to  one  or  more  years.  It 
is  unnecessary  to  say  that  where  the  accomplishment  of  the  cure  de- 
mands a  period  of  several  years,  the  treatment  must  be  intermittent 
and  greatly  varied,  so  as  to  suit  all  the  changing  circumstances  in  the 
condition  of  the  patient. 

Finally,  if  after  a  fair  trial  we  fail  to  accomplish  a  cure,  or  if  the  condi- 
tion of  the  child  will  not  warrant  even  the  attempt,  we  ought  as  far  as 
possible  to  seek  to  prevent  an  increase  of  the  deformity,  by  such 
means  as  our  ingenuity  may  suggest,  or  by  such  judicious  appliances 
and  general  management  as  we  have  seen  recommended  by  Dupuytren. 

South  says  that  he  has  seen  one  case  of  double  dislocation  in  which 
the  walking  was  at  first  extremely  difficult,  but  from  the  fifteenth 

'  Guerin,  op.  cit.,  pp.  81-3. 


CONGENITAL    DISLOCATIONS    OF    THE    KNEE.  747 

year  and  onwards  the  patient  so  improved,  that  at  the  twentieth  year 
scarcely  any  trace  of  the  peculiar  gait  could  be  discovered.^ 


§  14.  Congenital  Dislocations  of  the  Patella. 

Palletta  found  a  dislocation  of  the  patella  in  the  cadaver  of  a  young 
man,  which  he  supposed  to  be  congenital.^  Michaelis  has  reported 
two  cases ;  one  in  a  young  man  of  seventeen  years,  and  the  other  in  a 
girl  of  fourteen,  each  of  whom  affirmed  that  it  had  existed  from 
birth.^  Both  of  these  examples  presented  themselves  at  the  hospital 
on  account  of  hydrarthrosis  of  the  knee-joints,  and  Malgaigne,  who 
had  himself  seen  a  similar  case,  is  disposed  to  regard  them  all  as  ex- 
amples of  pathological  rather  than  congenital  luxations.  Periat  reports 
a  case  in  which  the  dislocation  was  only  produced  by  walking,  and  in 
relation  to  the  authenticity  or  pertinence  of  which  Malgaigne  seems 
also  to  entertain  a  doubt."* 

South  says  that  he  has  seen  a  congenital  dislocation  on  both  legs, 
in  an  aged  man.  The  patella  rested  entirely  upon  the  outer  faces  of 
the  external  condyles,  leaving  the  front  of  the  knee-joint  completely 
uncovered.  When  the  limbs  were  extended  the  patellae  could  be 
easily  made  to  resume  their  natural  positions,  but  on  the  patient's 
making  the  slightest  movement  they  were  again  displaced.  The 
knees  were  very  much  inclined  inwards,  the  feet  outwards,  and  his 
gait  was  difl&cult  and  unsteady.* 


§  15.  Congenital  Dislocations  or  the  Knee. 

The  head  of  the  tibia  has  been  found,  at  birth,  dislocated  forwards, 
backwards,  inwards,  outwards,  inwards  and  backwards,  outwards  and 
backwards,  and  simply  rotated  inwards. 

Most  of  these  luxations  were  incomplete ;  and  of  them  all,  the  dislo- 
cation forwards  has  been  observed  much  the  most  often. 

A  subluxation  forwards  of  the  head  of  the  tibia  has  been  seen  by 
Guerin  in  a  foetal  monster,  accompanied  with  extreme  retraction  of 
the  extensor  muscles  of  the  leg.*  Cruveilhier  has  dissected  a  foetus 
affected  with  a  similar  subluxation.^ 

In  these  examples  the  displacement  forwards  at  the  articular  surftice 
was  but  slight,  and  the  anterior  flexion  of  the  limb  inconsiderable ; 
but  when  the  dislocation  is  complete,  or  nearly  so,  the  deformity  is 
in  all  respects  very  much  increased ;  as  the  following  examples  will 
illustrate: — 

Dr.  D.  H.  Bard,  of  Troy,  Vermont,  has  reported  an  example  of 

'  South,  Note  to  Chelius,  op.  cit.,  voL  ii.  p.  245. 

2  Palletta,  Exercitationes  Patliologicse,  p.  91. 

3  Michaelis,  Rev.  Med.  Chirurg.,  torn.  xv.  p.  56. 
^  Periat,  Malgaigne,  op.  cit.,  torn.  ii.  p.  932. 

«  South,  Note  to  Chelius,  op.  cit.,  vol   ii.  p.  247.  ^  Guerm,  op.  cit.,  p.  63. 

^  Cruveilhier,  Atlas  de  I'Auat.  Patholog.,  2e  livr.,  pi.  2. 


748  CONGENITAL    DISLOCATIONS. 

complete  anterior  luxation  of  the  tibia,  seen  by  himself,  in  a  new-born 
infant.  The  leg  was  found  drawn  forwards  upon  the  thigh  at  an  acute 
angle,  so  that  the  toes  pointed  toward  the  face  of  the  child,  and  the 
bottom  of  the  foot  was  directed  forwards.  By  the  application  of 
moderate  force,  the  limb  could  be  straightened  and  even  flexed  com- 
pletely. These  motions  inflicted  no  pain.  It  was  especially  noticed 
that  in  bringing  down  the  leg  from  its  position  of  extreme  anterior 
flexion  (extension)  more  force  was  required  in  the  first  part  of  the 
manoeuvre  than  in  the  last;  and  that  if,  having  brought  the  leg  down, 
it  was  left  to  itself,  it  immediately  resumed  the  abnormal  position, 
moving  at  first  slowly,  but  after  a  time  much  more  rapidly. 

The  limb  was  confined  by  bandages  for  a  short  time,  and  it  did  not 
afterwards  show  any  disposition  to  return  to  its  unnatural  position. 
The  child  did  well,  and  when  it  began  to  use  its  legs,  no  difference 
could  be  discovered  between  them.^ 

Chatelain  was  consulted  in  relation  to  a  similar  case,  in  which  the 
restoration  of  the  limb  to  its  natural  position  was  also  easily  effected, 
and  by  means  of  three  metallic  splints,  applied  during  about  fifteen 
days,  the  cure  was  consummated.  Chatelain  directed,  however,  that 
the  leg  should  be  kept  flexed  upon  the  thigh  eight  days  longer.^ 

Kleeberg  found  a  child  with  the  leg  so  much  flexed  forwards  (ex- 
tended) upon  the  thigh  that  the  popliteal  region  became  the  lowest 
point  of  the  limb;  in  front  and  above  the  articular  extremity  of  the 
tibia -could  be  felt,  and  the  condyles  of  the  femur  made  a  correspond- 
ing projection  behind  into  the  popliteal  space.  This  was  plainly  an 
example  of  complete  luxation ;  and,  contrary  to  what  was  observed 
in  Bard's  case,  flexion  of  the  limb  backwards  was  difficult  and  painful. 

The  treatment  was  commenced  by  securing  the  limb  in  a  straight 
position  by  means  of  a  splint  and  roller;  subsequently,  Kleeberg  car- 
ried the  limb  back  to  an  obtuse  angle,  and  finally,  it  was  kept  eight 
days  in  a  position  of  extreme  flexion.  A  complete  cure  was  said  to 
have  been  accomplished  in  about  two  weeks.^ 

Guerin  has  seen  a  subluxation  backwards,  accompanied  with  a  slight 
rotation  of  the  head  of  the  tibia  outwards,  in  a  girl  fourteen  years  old; 
aad  which,  he  affirms,  was  congenital,  characterized  by  a  permanent 
flexion  (backwards)  of  the  leg  upon  the  thigh,  and  a  sliding  of  the 
condyles  of  the  tibia  backwards. 

This  girl  was  under  Guerin's  treatment,  but  with  what  result  is  not 
stated.'' 

Chaussier  found  both  tibiee  displaced  backwards  in  an  infant  other- 
wise deformed.* 

Robert  speaks  of  an  example  of  lateral  subluxation  in  a  man,  which 
had  existed  from  birth.  The  right  knee  was  thrown  inwards,  and  the 
left  outwards.'^ 

Guerin  "  operated"  publicly  upon  a  child,  two  years  old,  who  had  a 

■  Bard,  Amer.  Journ.  Med.  Sci.,  Feb.  1835,  p.  555,  from  Bost.  Med.  and  Surg. 
Journ.,  Nov.  26,  1834. 

^  Chatelain,  Bibliotheque  Med.,  torn.  Ixxv.  p.  85. 

^  Kleeberg,  Malgaigne,  op,  cit.,  p.  983.  ''  Guerin,  sur  les  Lux.  Congen  ,  p,  33. 

*  Chaussier,  Malgaigne,  op.  cit,,  p.  984,         ^  Robert,  Malg,,  op,  cit,,  p.  985. 


CONGENITAL    DISLOCATIONS    OF    THE    TOES.  749 

congenital  dislocation  of  the  head  of  the  tibia  backwards  and  inwards, 
accompanied  with  a  slight  rotation  of  the  leg  inwards.^  In  what  man- 
ner he  operated,  and  with  what  result,  he  does  not  inform  us. 

The  same  writer  speaks  of  a  subluxation  backwards  and  outwards, 
with  rotation  in  the  same  direction,  a  deformity  which,  he  afSrms,  is 
very  frequent,  and  which  appears  especially  after  birth,  although  the 
causes  which  produce  it  have  given  their  first  impulse  during  intra- 
uterine life. 

The  case  quoted  from  Robert,  by  Malgaigne,  as  an  example  of  dis- 
location inwards,  seems  to  have  been  rather  a  case  of  semi-rotation  of 
the  articular  surfaces,  the  inner  condyle  being  thrown  back  into  the 
popliteal  space,  while  the  outer  condyle  still  retained  its  natural  posi- 
tion. 

§  16.  Congenital  Dislocations  of  the  Tarsal  Bones. 

Under  this  general  term  may  be  included  all  those  varieties  of  sub- 
luxation of  the  several  bones  which  compose  the  tarsus,  and  which  are 
known  as  examples  of  talipes  or  club-foot ;  such  as  tibio-astragaloid 
luxations,  astragalo-scaphoid,  calcaneo-astragaloid,  calcaneo-cuboid,  &c. 

Although  these  deformities  may  properly  enough  claim  a  place  in 
a  chapter  on  congenital  dislocations,  they  have  so  long  been  the  sub- 
jects of  special  treatises  as  to  justify  their  exclusion  from  the  present 
volume. 

§  11.  Congenital  Dislocations  of  the  Toes. 

Observed  occasionally  at  the  metatarso-phalangeal  articulations ; 
the  articular  facets  of  the  first  phalanges  suffering  a  subluxation  up- 
wards, or  laterally  upon  the  corresponding  metatarsal  bones. 

Guerin  has  noticed  especially  a  congenital,  lateral  subluxation  of  the 
great  toe.^ 

1  Guerin,  sur  les  Lux.  Congen.,  p.  33.  ^  Guerin,  op.  cit.,  p.  34. 


INDEX. 


PART  I.— FRACTURES. 


Abscess  in  fracture  of  the  sternum,  171 
Acetabulum,  340 
Acromion  process,  210 
Amesburv's  thigh  splint,  405 
Anatomical  neck  of  humerus,  230,  232 
Anaplasty  in  fractures  of  the  septum  narium, 

103 
Anchylosis  after  Colles's  fracture,  280 

excision  for  anchylosis  of  knee,  449 
"Apparatus  immobile,""  61 

in  fractures  of  the  leg,  470 
Astragalus,  477 
Atlas,  167 

and  axis,  167 
Axis,  164 
Ayres,  compound  fracture  of  clavicle,  188 

humerus,  237 

Badly  united  fracture  of  leg,  475 
Baker,  fracture  of  maxilla  superior,  112 
Barton's  bran  dressing,  68,  474 

bandage  for  fractured  jaw,  134 

trephining  vertebree,  153 

fracture  of  lower  end  of  radius,  279 

fracture-bed,  429 
Base  of  acetabulum,  340 

of  condyles  of  femur,  436 
Bauer's  wire  splints,  472 
Bending  of  bones,  77 
Bigelow,  fracture  of  axis,  165 

stellate  fracture  of  lower  end  of  radius,  277 
Boardman,  fracture  of  zygoma,  114 

perineal  band,  425 
Body  of  the  scapula,  204 
Bodies  of  the  vertebrse,  155 
Bond's  elbow  splint,  250 

radius  splint,  283 
Bowen's  thigh  apparatus,  411 
Box  for  leg,  474 
Boyer's  thigh  splint,  406 
Brainard,  perforator,  75 

fracture  of  anatomical  neck  of  humerus, 
217 
Buck,  lower  jaw,  117 
Burges's  thigh  apparatus,  409 

CALCA:yErjr,  477 
Carpal  bones,  325 
Cartilages,  173,  178 

of  ribs,  173 
Carved  splints,  radius,  289 


Cervical  ligaments,  strains  of,  161 

vertebrae,  bodies  of  five  lower.  160 
axis,  164 
atlas,  167 
atlas  and  axis,  167 
Chapin's  thigh  apparatus,  415 
Chronic  rheumatic  arthritis,  373,  374 
Children,  fracture  of  femur,  425,  431 
Clark's  case  of  fracture  of  pelvis,  334 
Clavicle,  179 

partial  fractures,  180 
repair  of  fractures,  187 
Cline,  trephining  vertebrae,  153 

fracture  of  atlas,  167 
Coates,  fracture-bed,  429 

bran  dressings,  68 
Coccyx,  347 

Colby,  neck  of  femur  within  capsule,  370 
Colles"s  fracture,  examples,  273 
Common  signs  of  fracture,  41 
Compress,  pasteboard,  for  fractured  jaw,  135 
Compound  fractures,  67 
forearm,  324 
thigh,  Gilbert  on,  421 
patella,  442 
tibia  and  fibula,  458 
leg,  468,  474 
Concussion  of  spinal  marrow,  162 
Condyles  of  humerus,  255 
internal,  260 
external,  262 
base,  244 

base  and  between  condyles,  252 
of  femur,  434 

external,  434 
internal,  435 
base,  436 

between  condyles,  436 
Congenital,  38,  235,  449 

Cooper,  Sir  Astley,  fracture  of  olecranon  pro- 
cess, 313 
neck  of  femur  within  capsule,  355 
patella,  447,  448 
Coracoid  process,  212 
Coronoid  process  of  ulna,  299 

Liston's  case,  302 
Cotyloid  cavity,  340 

Counter-extension  by  adhesive  plaster,  420 
Cradle  for  leg,  473 

Crandall,  extension  in  fracture  of  leg,  468 
Cricoid  cartilage,  145 


752 


INDEX — FEACTURES, 


Cronyn,  fracture  of  lumbar  vertebrae,  157 
Crosby,  neck  of  femur  within  capsule,  377 
external  condyle,  434 

Dalton,  John  C,  fracture  of  neck  of  femur, 

359 
Daniel's  thigh  apparatus,  413 

fracture-bed,  429 
Daniell,  femur,  413 
Day's  elbow  splint,  249 
Deformities  of  legs,  475 
Delayed  or  non-union,  68 

humerus,  239 
Dextrine,  62 
Diagnosis^  general,  41 
DieflFenbach,  tenotomy  in  fracture  of  olecranon 

process,  315 
Dislocation  of  humerus,  differential  diagnosis, 

229 
Division  of  fractures,  general,  35 
Dorsal  vertebrae,  159 
Dorsey,  fracture  of  patella,  446 
Douglas,  tibia,  453 
Dudley,  treatment  of  fractures  by  bandages, 

417 
Dugas,  sign  of  dislocation  of  humerus,  229 

thigh  apparatus,  414 
Dupuytren's  case  of  fracture  of  a  dorsal  ver- 
tebra, 159 

body  of  a  lower  cervical  vertebr.i,  160 

dressing  for  fracture  of  fibula,  455 

Elbow  splint,  Physick's,  249 

Kirkbride's,  249 

Day's,  249 

Rose's,  250 

Welch's,  250 

Bond's,  250 

the  author's,  251 
Ellis,  fracture  of  lower  jaw,  118 
Else,  fracture  of  axis,  164 
Emphysema  in  fracture  of  ribs,  176,  177,  178 
Endless  screw  for  extension  of  thigh,  426 
Enos,  coronoid  process  of  ulna,  307 
Epicondyle  of  humerus,  external,  259 

internal,  255 
Epiphyseal  separations,  36 

acromion,  210 

humerus,  upper  end,  231,  233 
lower  end,  245 

femur,  upper  end,  351 

trochanter  major,  390 
Epitrochlea,  255 
Etiology,  general,  37 
Eve,  non-union  of  ribs,  175 

patella,  442 
Exciting  causes,  general,  37 
Experiments  on  bending,  78 

on  partial  fractures,  84,  87,  88 
External  epicondyle  of  humerus,  259 

condyle  of  humerus,  262 
femur,  434 
Extension  of  thigh  by  adhesive  plaster,  419 

Fauger,  Colles's  fracture,  284 
Felt  splints,  58 
Femur,  348 

neck,  within  capsule,  349 

differential  diagnosis,  385 

without  capsule,  within  and  without  cap- 
sule, 388 

trochanter  major  and  base  of  neck,  389 


Femur — 

epiphysis  of  trochanter  major,  390 

shaft,  392 

external  condyle,  434 

internal  condyle,  435 

between  condyles,  436 
Fergusson's  arm  dressing,  249 
Fibula,  453 
Fingers,  329 
Fissures,  90 

neck  of  femur,  351 
Forearm,  316 

Fore's  case  of  fracture  of  hyoid  bone,  139 
Flagg's  thigh  apparatus,  411 
Flint,  J.  B.,  femur,  414 
Four-tailed  bandage  for  broken  jaw,  135 
Fracture-beds,  428 

Jenks,  428 

Hewson,  429 

Barton,  429 

Coates,  429 

Daniels,  429 

Burges,  409 
Fracture-box,  474 

Gangrene,  after  fracture  at  base  of  condyles 
of  humerus,  248 

Dupuytren's  cases  after  fracture  of  radius, 
290 

Robert  Smith's  cases,  290 

Norris,  292 

after  fracture  of  forearm,  318 

leg,  from  tight  roller,  417 

patella,  447 

from  tight  bandages,  452 

leg,  from  tight  bandage,  465 

from  use  of  "apparatus  immobile,"  470 
Gibson,  bandage  for  fractured  jaw,  134 

fracture  of  clavicle,  189 

of  coracoid  process,  212 
Gilbert,  apparatus  for  broken  femur,  420 
Glenoid  cavity  of  scapula,  comminuted,  209 
Granger,  fracture  of  epicondyle,  255,  257 
Greater  tubercle  of  humerus,  221,  230,  232 
Greenwood,  fracture  of  lower  cervical  verte- 
bra, 160 
Gutta-percha  splints,  59 

Harris,  separation  of  upper  maxillary  bones, 

109 
Harrold,  lumbar  vertebrae,  158 
Hartshorne,  thigh  apparatus,  415- 
Hays,  radial  splint,  283 
Hayward,  lower  jaw,  128 
Head  of  femur,  351 

of  radius,  269 

and  anatomical  neck  of  humerus,  215 

and  neck  of  humerus,  longitudinal  frac- 
ture, 221 
Hewson,  fracture-bed,  429 
Horner,  thigh  apparatus,  414 
Humerus,  215 

anatomical  neck,  217 

head  and  neck,  216 

tubercles,  220 

longitudinal  fracture  of  head  and  neck, 
221 

surgical  neck,  223 

upper  epiphysis,  223 

differential  diagnosis,  228 

shaft,  235 

base  of  condyles,  244 


INDEX  —  FEACTUEES. 


753 


Humertis — 

with  splitting  of  condyles,  252 

condyles,  255 

internal  epicondyle,  255 

external  epicondyle,  259 

internal  condyle,  260 

external  condyle,  262 

delayed  union,  239 

dislocation  of,  229 
Hutchinson,  leg  splint,  466 
Hyoid  bone,  138 

Ilium,  337 

Immovable  apparatus,  61 

leg,  470 
Impacted  fractures,  36 

head  and  neck  of  humerus,  216 

tubercles,  220 

neek  of  femur  within  capsule,  351 
without  the  capsule,  382 
Inferior  maxilla,  116 

Interstitial  absorption  of  neck  of  femur,  373 
Intra-uterine  fracture,  38,  235,  449 
In  utero,  38,  235 

fracture  of  tibia,  449 
Internal  condyle  of  humerus,  260 

femur,  435 
Interdental  splints,  130 
Ischium,  335 

Jackson,  acromion  process,  211 
Jarvis's  adjuster,  467 
Jenks,  fracture-bed,  428 
Johnson,  neck  of  femur,  359,  364 

Key,  lumbar  vertebrae,  158 
Kimball,  fracture  of  femur,  413 
Kirkbride,  elbow  splint,  249 

Lknte,  fracture  of  dorsal  vertebra,  159 

femur,  422 

non-union,  73 

coronoid  process  of  ulna,  307 

pelvis,  332 
Lewitt,  patella,  442 
Liston,  thigh  splint,  403 

leg  splint,  471 
Lockwood,  fracture  of  humerus  at  birth,  235 
Long  splints,  55 

Lonsdale,  extension  in  fracture  of  humerus, 
238 

patella,  448 
Lower  jaw,  116 
Lumbar  vertebrae,  157 

Malar  bone,  104,  110 
Many-tailed  bandage,  53 
March,  acromial  separations,  211 

neck  of  femur,  367 
Malgaigne,  apparatus  for  fracture  of  leg,  474 
Maxilla,  superior,  108 
Mayo,  neck  of  femur,  377 
McDowell,  remarkable  displacement  of  head 
of  humerus,  217 

separation  of  upper  epiphysis,  '224 
Metacarpus,  326 
Metatarsus,  482 
Metallic  splints,  55 
Monahan,  fracture  of  astragalus,  477 
Morbus  coxEe  senilis,  373 

Morland,  statistics  of  fracture  of  tibia   and 
fibula,  458 
48 


Mott,  prognosis  in  Colles's  fracture,  281 

fracture  of  femur,  407 

electricity  in  non-union,  73 
Mussey,  fracture  of  coracoid  process,  212 

neck  of  femur,  359 
Mutter's  "clamp,"  131 

neck  of  radius,  267 

Neck  of  femur,  348 

within  capsule,  349 

prognosis,  355 

without  capsule,  382 
Neck  of  humerus,  anatomical,  216,  221 

surgical  neck,  223 
Neck  of  lower  jaw,  119 
Neck  of  scapula,  208 

signs  of  fracture,  229 
Neill,  maxilla  superior,  112 

coracoid  process,  212 

fracture  of  patella,  446 
thigh,  410 

leg,  simple  fracture,  467 
compound  fracture,  468 
Neck  of  radius,  267 
Nelaton,  radial  splint,  282 
Non-union,  68 

humerus,  239 

lower  jaw,  125 

ribs,  175 
Norris,  delayed  and  non-union,  68 

astragalus,  479 

gangrene  from  bandages,  293 

tibia,  452 
Nose,  fracture  of,  96 
Nott,  wire  splints,  56 

thigh  apparatus,  408 

Odontoid  process  of  axis,  164 
Olecranon  process,  308,  313 

tenotomy,  315 
Ossa  nasi,  96 

Radius,  266 
Radial  splint,  282,  288 
Radius  and  ulna,  316 

Reduction    of  fractures :    general   considera- 
tions, 42 
Refracture  of  badly-united  legs,  475 
Repair  of  fracture,  45 
Resection  for  badly-united  fractures,  475 
Ribs,  173 

cartilages  of,  173,  178 
Rim  of  acetabulum,  343 
Rodet,  neck  of  femur,  360 
Rogers,  trephining  vertebras,  153 
Roller,' 63 
Rose,  elbow  splint,  250 

Sacrum,  346 

Sacro-iliac  symphysis,  347 
Salter's  cradle  for  leg,  473 
Sanborn,  patella,  442 

thigh,  413 
Sargent,  separation  of  upper  maxillary  bones, 

108 
Scapula,  204 

body,  204 

neck,  208 

acromion  process,  210 

coracoid  process,  212 
Scultetus's  bandage,  54 
"Setting  bones,"  42 


754 


INDEX — FRACTUEES. 


Semeiology,  general,  41 
Septum  narium,  101 

anaplasty.  103 
Shaft  of  humerus,  235 

radius,  271 

ulna.  294 

femur,  392 
Shoulder-i'oint ;  differential  diagnosis  of  acci- 
dents, 228 
Side  splints,  55 
Sling  for  broken  jaw,  135 
Smith,  E.  P.,  radial  splint,  283 
Smith,  H.  H.,  fracture  of  neck  of  femur,  364 
Smith,  Nathan  R.,  fracture  of  femur,  407 
Smith,  Robert,  head  of  humerus,  219 
Smith,  Stephen,  fracture  of  lower  jaw,  118 

non-union,  125 
Spencer,  fracture  of  humerus  at  base  of  con- 
dyles, 254 
Spinal  marrow,  concussion,  162 
Spinous  processes  :  vertebrae,  147 

ilium,  337,  338 
Splints,  55 
Starch  bandage,  61 

leg,  470 
Sternum,  168 
Stone,  fracture  of  humerus,  237 

base  of  condyles  and  resection,  254 
Styloid  process  of  radius,  278 
Suetin's  dressing,  61 
Surgical  neck  of  humerus,  223,  231,  233 
Swan,  neek  of  femur  within  capsule,  358 
Swing  box  for  leg,  473 
Symph;fses  of  pelvis,  332 

pubes,  347 

sacro-iliac,  347 
Symphysis  pubis,  separation  of,  347 

Tarsus,  477 

astragalus,  477 

calcaneum,  477 
Tenotomy  in  fractures  of  olecranon  process, 

315 
Thompson,  fracture  of  lumbar  vertebrae,  158 
Thyroid  cartilage,  143 
Thyroid  and  cricoid  cartilages,  143 
Tibia,  449 

Tibia  and  fibula,  457 
Toes,  483 

Transverse  processes  of  spine,  149 
Treatment  of  fractures,  general,  51 


Trephining  for  fracture  of  vertebrae,  153 
Trochlea  of  humerus,  260 
Tubercles  of  humerus,  220,  230,  232 

Ulna,  resection  of,  293 
Ulna,  294 

shaft,  294 

coronoid  process,  299 

olecranon  process,  308 
Upper  epiphysis,  hum.erus,  231 

femur,  351 
Upper  maxillary  bones,  108 

Van  Buken,  "W.  H.,  fracture  of  humerus,  234 
Vanderveer,  fracture  in  utero,  40 
Vandeventer,  fracture  of  vertebral  arch,  150 
Velpeau.  mode  of  dressing  fractures  with  de.x- 

trine  and  rollers,  62 
Vertebral  arches,  150 
Vertebrse,  147 

spinous  processes,  147 
transverse  processes,  149 
vertebrql  arches,  150 
bodies,  155 

lumbar,  157 
dorsal,  159 
cervical,  160 
axis,  164 
atlas,  167 
atlas  and  axis,  167 

Waters,  compound  fracture  of  humerus,  234 
Warren  on  anchylosis  at  elbow-joint,  265 
Watson,  fracSure  of  lower  jaw,  119 

lower  epiphysis  of  humerus,  246 

patella,  441 
Weber,  plaster  of  Paris  bandages,  66 
Welch,  veneered  splints,  60 

shoulder,  234 

elbow,  250 

radius,  282 

thigh,  408 

leg,  471 
Whittaker,  pelvis,  335 
Wills,  internal  condyle  of  femur,  435 
Wire  splints,  56 
Wood,  fracture  of  patella,  446 
Wooden  splints,  57 
Wrist,  325 

Zygomatic  arch,  113 


IXDEX — DISL0CATI0X3. 


755 


PAET  II.— DISLOCATIONS. 


Ancient  luxations,  492 

inferior  maxilla,  498 

spine,  506 

clavicle,  outer  end,  527 

humerus.  531 

head  of  radius  forwards,  571 

radius  and  ulna  backwards,  582 

thumb,  609 

femur,  662 
Andrews,  inferior  maxilla,  496 
Ankle-joint,   684 
Annan,  dislocation  of  femur,  648 
Anomalous  dislocations  of  the  hip,  658.     See 

Femur. 
Atlas,  dislocations  of,  514 
Ayres,  dislocation  of  cervical  vertebra,  511. 

Batchelder,  head  of  radius,  571,  575 

thumb,  612 
Biceps,  rupture  or  displacement  of,  568 
Blaekman,    ancient  dislocations   of  humerus, 
554 

femur  reduced  after  six  months,  663 
Bloxham's  dislocation  tourniquet,  636 
Brainard,    reduction    of  ancient   luxation   of 
elbow,  587 

reduction  of  femur  by  a  novel  method,  653 

Carpus,  595 

backwards,  597 

forwards,  600 

congenital,  740 
Carpal  bones  among  themselves.  603 
Carpo-metacarpal  articulation,  605 
Cartilages,  of  ribs  from  one  another,  718 

in  knee-joint,  682 
Cervical  vertebrae,  507 

six  lower  cervical  vertebrae,  507 

atlas  upon  axis,  514 

head  upon  atlas,  515 
Clavicle,  dislocations  of,  518 

sternal  end  forwards,  519 

sternal  end  upwards,  523 

sternal  end  backwards,  524 

acromial  end  upwards,  526 

acromial  end  downwards,  531 

under  eoracoid  process,  533 

conarenital,  734 
Clove  hitch,  494 
Compound  pulleys,  494 
Compound  dislocations  of  the  long  bones,  712 

reduction  in,  717 

non-reduction  in,  720 

amputation  in,  720 

tenotomy  in,  721 

resection  in,  722 
Congenital  dislocations;  general  observations 
and  history,  727 

general  etiology,  728 

inferior  maxilla,  730 

spine,  733 


Congenital  dislocations — 

pelvic  bones,  734 

sternum,  734 

clavicle,  734 

shoulder,  735 

radius  and  ulna  backwards,  739 

head  of  radius,  739 

wrist,  740 

fingers,  740 

hip,  741 

patella,  747 

knee,  747 

tarsus,  749 

toes,  749 
Cooper,  Sir  Astley,  method  of  reducing  dislo- 
cation of  humerus,  547 
Coxo-femoral  dislocations,  619.     See  Femur. 
Crosby,  dislocation  of  thumb,  612 

ancient  dislocation  of  elbow,  587 

Damainville,  statistics  of  dislocations  of  fe- 
mur, 637 
Direct  causes  of  dislocations,  489 
Dislocations,  485 

Division  and  nomenclature  of  dislocations,  487 
Dorsal  vertebrae,  504 
Double  dislocation  of  lower  jaw,  495 
Dupierris,  femur  reduced  after  six  months,  663 
Dynamometer,  636 

Elbow-joint,  579 

Exciting  causes,  general,  489 

Extension  by  a  twisted  rope,  494 

Femur,  dislocations  of,  619 

dislocation  on  dorsum  ilii,  621 

reduction  by  manipulation,  626 

reduction  by  extension,  632 
dislocation  into  great  ischiatic  notch,  644 
dislocation  into  foramen  thyroideum,  649 
dislocation  upon  the  pubes,  653 
anomalous  dislocations  of  the  femur,  658 

downwards  and  backwards  upon  the 
body  of  the  ischium,  659 

downwards  and  backwards  into  lesser 
ischiatic  notch,  660 

behind  the  tuber  ischii,  660 

directly  up,  660 

directly  down,  661 

forwards  into  perineum,  661 

ancient  dislocations,  626,  662 

partial  dislocations,  665 

with  fracture,  666 

in  children,  620 

congenital,  741 
Fenner,  dislocation  of  femur  on   dorsum  ilii, 

623 
Fibula,  upper  end  forwards,  694 
backwards,  695 
lower  end,  696 


756 


INDEX — DISLOCATION'S. 


"Fifth,"  dislocation  of  femur,660 

Fingers,  dislocations  of  first  phalanx,  607,  616 

second  and  third,  617 

congenital,  740 
Foot,  dislocation  outwards,  685.     See  Tibia. 
Fountain,  dislocation  of  femur  upon  pubes,  656 

Gazzam,  rotation  of  patella  on  its  inner  mar- 
gin, 674 
General  division,  487 
General  direct  or  exciting  causes,  489 
General  predisposing  causes,  488 
General  prognosis,  492 
General  pathology,  491 
General  treatment,  492 
General  symptoms,  489 

Gibson,  ancient  dislocation  of  humerus,  557 
Gilbert,  A.  W.,  dislocation  of  lower  jaw,  496 
Graves,  dislocation  of  dorsal  vertebrse,  505 
Gunn,  dislocation  of  thigh  on  dorsum  ilii,  623 

Hartshorne,  reduction  of  humerus  by  ma- 
nipulation  (note),  559 
Head  upon  the  atlas,  615 
Hinckerman,  cervical  vertebrae,  510 
Hodge,  statistics  of  dislocations  of  the  femur 

638 
Horner,  partial  dislocation  of  fourth  cervical 

vertebra,  508 
Howe,  reduction  of  dislocation  of  the  hip  by 

manii^ulation,  631 
Humerus,  dislocations  of,  533 
dojvnwards,  533 
forwards,  559 
backwards,  564 
partial,  567 
ancient,  551 
with  fracture,  558 
congenital,  735 
Humero-scapular  dislocation,  533.     See  Hu- 
merus. 

Ilio-pubie  dislocation  of  femur,  653 
Indian  "puzzle,"  614 
Inferior  maxilla,  495 

double  dislocation,  495 

single  dislocation,  500 

congenital  dislocation,  730 
Ingalls,   reduction   of  dislocation  of    hip  by 

manipulation,  631 
Internal  derangement  of  knee-joint,  682 
Ischio-pubic  dislocation  of  femur,  649 
Ischiatic  dislocation  of  femur,  644 

Jartis's  adjuster,  495,  550,  635 


KiRKBRiDE,  dislocation  of  the  femur  upon 
posterior  part  of  the  body  of  the  ischium,  659 

Knee,  slipping  of  semilunar  cartilages,  682. 
See  Tibia. 

Krackowitzer,  dislocation  of  head  of  radius  in 
delivery,  571 

La  Mothe,  method  of  reducing  dislocation  of 

humerus,  547 
Lehman,  spontaneous  dislocation  of  shoulder, 

534 

Lente,  fifth  cervical  vertebra,  with  fracture,  508 
fifth    cervical  vertebra  without  fracture 

508 
femur  directly  upwards,  658 


Levis,  reduction  of  dislocation  of  thumb,  613 
Long  bones,  compound  dislocation  in,  712 
Lower  jaw,  495.     See  Superior  maxilla. 
Lumbar  vertebrje,  503 

Maekoe,  on  reduction  of  dislocation  of  femur 
623,  632 
head  of  radius  backwards,  575 
femur  with  fracture,  reduced,  668 
Maxson,  dislocation  of  cervical  vertebrse,  511 
May,  reduction  of  old  dislocation  of  humerus 

550 
Mercer,  on  partial  dislocations  of  humerus,  569 
Metacarpus,  605 

Metacarpo-phalangeal  articulation,  607 
Metatarsus,  708 
Moore,  on  reduction  of  dislocation  of  femur 

623 
Mussey,  dislocation  of  thumb,  611 
ancient  dislocation  of  elbow,  587 

NoRRis,  ancient  dislocations  of  the  humerus 
557 
dislocation  of  humerus  mistaken  for  a  con- 
tusion, 562 
compound  dislocation  of  thumb,  614 
partial  luxation  of  patella,  with  fracture, 
670 

OcciPiTO-ATLOiDEAN  dislocations,  515 

Parker,  head  of   humerus    in   sub-scapular 
fossa,  660 

backwards,  564 

head  of  radius  backwards,  575 

head  of  radius  outwards,  677 

femur  into  perineum,  661 
Patella,  outwards,  669 

inwards,  672 

on  its  axis,  672 

on  its  inner  margin,  673 

upwards,  675 

congenital,  747 
Pathology,  general,  491 
Pelvis,  traumatic  separations,  332  (Part  I.) 

congenital,  734 
Perineal  dislocation,  of  femur,  662 
Phalanges,  thumb  and  fingers,  607 

toes,  710 
Pope,  dislocation  of  femur  into  perineum,  662 
Predisposing  causes,  general,  488 
Prognosis,  general,  492 
Pseudo-luxations  of  inferior  maxilla,  500 
Pulleys,  494 

Purple,  dislocation  of  cervical  vertebree,  509 
"  Puzzle,"  Indian  toy  :  applied  to  reduction  of 
dislocations  of  small  joints,  614 

Radius,  head  dislocated  forwards,  570 

backwards,  575 

outwards,  577 

outwards  and  backwards,  589 

inwards,  592 

inwards  and  upwards,  592 

congenital,  739 
Radius  and  ulna,  dislocation  backwards,  579 

congenital,  739 

outwards,  588 

inwards,  592 

forwards,  594 
Radio-carpal  articulation,  595.     See  Carpus. 
Radio-ulnar  articulation,  inferior,  601 


IXDEX — DI3L0CATI0XS. 


tOi 


Reid,   reduction   of   dislocation  of  femur  by 

manipulation,  632 
E.ibs  from  vertebrse,  516 

from  sternum,  517 

one  cartilage  upon  another,  518 
Rochester,  sternal  end  of  clavicle  upwards,  523 
Rudiger,  dislocation  of  dorsal  vertebrse,  506 

Sacro-sciatic  dislocation  of  femur,  644 
Sanson,  third  cervical  vertebra,  509 
Schuck,  dislocation  of  cervical  vertebra,  510 
Shoulder,  dislocation  of,  533.     See  Hiunerus. 
Single  dislocation  of  lo-prer  jaw,  500 
"Sixth"'  dislocation  of  femur,  658 
Skey,  method  of  reducing  dislocation  of  hu- 
merus, 549 
Slipping  of  the  semilunar  cartilages    of  the 

knee-joint,  682 
Smith.  Nathan,  on  reduction  of  dislocation  of 
the  humerus,  546 
reduction  of  femur  by  manipulation,  628 
Spencer,  dislocation  of  cervical  vertebra,  509 
Spine,  502.     See  VertebrcB. 
Sternum,  diastasis,  168  (Part  I.) 

congenital  dislocation.  734 
Subeoracoid  dislocation  of  humerus,  559,  561 
Subclavicular  dislocation  of  humerus,  560 
Subcotyloid  dislocations  of  femur,  661 
Subglenoid  dislocation  of  the  humerus,  533 
Subpubic  dislocation  of  femur,  653 
Subspinous  dislocation  of  humerus,  564 
Swan,  dislocation  of  dorsal  vertebra,  506 
Symptomatology,  general,  489 

Tarsus,  697 

astragalus,  697 

astragalo-calcaneo-scaphoid,  703 

calcaneum,  704 

middle  tarsal  dislocation,  705 

OS  cuboides,  706 

OS  seaphoides,  706 

cuneiform  bones,  706 

congenital,  749 
Thigh,  619.     See  Femur. 
Thumb,  first  phalanx,  607 
backwards,  611 
forwards,  615 

second  phalanx,  617 


Tibia,  dislocation  of  upper  end,  675 
backwards,  679 
forwards,  678 
outwards,  679 

inwards,  681 

backwards  and  outwards,  681 
congenital,  747 
lower  end,  inwards,  687 
outwards,  689 
forwards,  691 
backwards,  693 
Tibia,  dislocation  of  lower  end,  684 
inwards,  685 
outwards,  689 
forwards,  691 
backwards,  693 
Tibio-tarsal  luxations,  684 
Toes,  710 

congenital,  749 
Treatment,  general,  492 

Trowbridge,  head  of  humerus  backwards,  564 
Twisted  rope,  extension,  494 

Ulna,  upper  end  backwards,  578 
lowe*  end  backwards,  601 
forwards,  602 
Unilateral  luxation  of  lower  jaw,  500 

Yax  Bfeen,  TV.  H.,  dislocation  of  humerus 
backwards,  564 

reduction  of  femur  by  manipulation,  639, 
651 
Vertebrae,  502 

lumbar,  503 

dorsal,  504 

six  lower  cervical,  507 

atlas  upon  axis,  514 

head  upon  atlas,  515 

congenital  dislocations,  733 

TVaeren,  humerus  with  fracture,  558 

Watson,  dislocation  of  patella  outwards,  670 

Wells,  dislocation  of  tibia,  682 

Windlass  for  extension,  494 

Wood,  dislocation  of  cervical  vertebrae.  511 

humerus,  with  fracture,  560 
Wrist,  595.     See  Carpus. 


THE    EXD. 


ERRATA. 


Page  S6,line  20,/o/-  '•  one  hundred  and  four  fractures,"  read  "  twelve  partial  fractures." 
"      "     "     31, /or  "Symes,"  read  "Syme." 

"    269,  270,  272,  and  273, /or  "proned"   and    "supined,"   read   "pronated'    and 
"supinated." 


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clearly  and  comprehensively,  albeit  too  diffusely,  !  vice  given  in  the  coucluding  paragraph  above,  would 
written,  are  incontestable.  They  have  been  suffi-  be  to  provide  himself  with  a  c  jp/  of  tne  bjuk  from 
ciently  endorsed  by  the  verdict  of  his  countryraea  which  it  has  been  taken,  and  diligently  to  con  its 
in  the  rapid  exhaustion  of  the  first  edition,  and  tney  instructive  pages.  They  may  secure  to  him  many 
■would  certainly  meet  with  a  similar  reward  in  the  a  triumph  and  fervent  blessing.— il??i.  Journal  Med. 
United  States  were  the  volume  placed  within  the  j  Sciences,  April,  IS53. 


ALLEN    (J.    M.),    M.  D., 

Professor  of  Anatomy  in  the  Pennsylvania  Medical  College,  &c. 

THE  PRACTICAL  ANATOMIST;  or.  The  Student's  Guide  iu  the  Dissecting- 

ROOM.    With  266  illustratioES.    In  one  handsome  royal  12mo.  volume,  of  over  600  pages,  lea- 
ther.    S2  25. 

However   valuable    may    be    the    "  Dissector's  I  ally  recommend  it  to  their  attention. — WestemLan- 
Guides"  which  we,  of  late,  have  had  occasion  to     ce  . 

notice,  we  feel  confident  that  the  work  of  Dr.  Allen  -^ye  believe  it  to  be  one  of  the  most  useful  works 
is  superior  to  any  of  them.  We  believe  with  the  ^^.^  j.^^  subiect  ever  written.  It  is  handsomelv 
author,  that  none  is  so  fully  illustrated  as  this,  and  illustrated,  well  printed,  and  will  be  found  of  con- 
the  arrangement  of  the  work  is  such  as  to  facilitate  ^renient  size  fur  use  in  the  dissecting-room.— ilfed. 
the  labors  of  the  student  in  acquiring  a  thorough  Examiner. 
practical  knowledge  of  Anatomy.    We  m.ost  cordi-  | 


ANATOMICAL   ATLAS. 

By  Professors  H.  H.  Smith  and  W.  E.  Horner.,  of  the  University  of  Pennsyl- 
vania.    1  vol.  Svo.,  extra  cloth,  with  nearly  650  illusiraiions.    i]^"  See  Sjiith,  p.  27. 


ABEL  (F.    A.),    F.  C.S.    AND    C.    L.    BLOXAM. 
HANDBOOK  OF  CHEMISTRY,  Theoretical,  Practical,  and  Technical;  with  a 

Recommendatory  Preface  by  Dr.  Hofmann.  In  one  large  octavo  volume,  extra  cloth,  of  662 
pages,  with  illustrations.    $3  25. 

ASHWELL   (SAMUEL),   M.D., 

Obstetric  Physician  and  Lecturer  to  Guy's  Hospital,  London. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  PEGULL^R  TO  WOMEN. 

Illustrated  by  Cases  derived  from  Hospital  and  Private  Practice.  Third  American,  from  the  Third 
and  revised  London  edition.     In  one  octavo  volume,  extra  cloth,  of  528  pages.     $3  00. 
The  most  useful  practical  work  on  the  subject  in  I      The  most  able,  and  certainly  the  most  standard 
the  Eno-lish  lan-^uaee.  — BosJon  Med.  and  .Swrg-.     and  practical,  work  on  female  diseases  that  we  have 
Journal'  °  \  yet  seen.— Medico-Chtrurgtcal  Review. 

ARNOTT   (NEILL),  M.  D. 
ELEMENTS    OF    PHYSICS;    or  Natural  Philosophy,  G-eneral  and  Medical. 

Written  lor  imiversal  use,  in  plain  or  non-technical  language.  A  new  edition,  by  Isaac  Hays, 
M.  D.  Complete  in  one  octavo  volume,  leather,  of  484  pages,  with  about  two  hundred  illustra- 
tions.    $2  50. 

BIRD  (GOLDING),  A.  M.,  M.  D.,  &.c. 
URINARY     DEPOSITS:     THEIR     DIAGNOSIS,    PATHOLOGY,    AND 

THERAPEUTICAL  INDICATIONS.  Edited  by  EorarxD  Lloyd  Birkett,  M.  D.  A  new 
American  from  the  fifth  and  enlarged  London  edition.  With  eighty  illustrations  on  wood.  In  one 
ha^drome'om^o  volume,  of  a3out°400  pages,  extracloth.     $2  00.     ^Just  Issued.) 

The  death  of  Dr.  Bird  has  rendered  it  necessary  to  entrust  the  revision  of  the  present  edition  to 
other  hands  and  in  his  performance  of  the  duty  thus  devolving  on  him.  Dr.  Birteit  has  sedulously 
endeavored^o  Irrv  o^^^^  author's  plan  by  introducing  such  new  matter  and  modifications  ot 
the  tex°  as  the  proLess  of  science  has  called  for.  Notwuhstandmg  the  utmost  care  to  keep  the 
me  lexi  as  luc  piuj,  _„„„„;;,  thp*e  additions  have  resulted  m  a  considerable  enlargement. 

Tif  tSetreVho'S  tS^t  UwFu  b^  Sund  fully  up  to  the  present  condition  of  the  subject,  and.that 
the  reputation  of  the  volume  as  a  clear,  complete,  and  compendious  manual,  will  oe  luUy  mamtamed. 


BLANCHARD   &    LEA'S   MEDIOAIj 


BUDD  (GEORGE),  M.  D.,  F.  R.  S., 

Professor  of  Medicine  in  King's  College,  London 

ON  DISEASES   OP  THE   LIVER.      Third  American,  from   the  third  an^ 

enlarged  London  edition.    In  one  very  handsome  octavo  volume,  extra  cloth,  with  four  beam 

fully  colored  plates,  and  numerous  wood-cuts.     pp.  500.     $3  00. 

Has  fairly  established  for  itself  a  place  among  tlie 
classical  medical  literature  of  Englnnd.— British 
and  Foreign  Medico-Chir.  Review,  July,  1857. 


Dr.  Badd's  Treatise  on  Diseases  of  the  Liver  is 
now  a  standard  work  in  Medical  literature,  and  dur- 
ing the  intervals  which  have  elapsed  between  the 
successive  editions,  the  author  has  incorporated  into 
the  text  the  most  striking  novelties  which  have  cha- 
racterized the  recent  progress  of  hepatic  physioloo-y 
and  pathology;  so  that  although  the  size  of  the  book 


IS  not  perceptibly  changed,  the  history  of  liver  dis 
eases  is  made  more  complete,  and  is  kept  upon  a  levt 
with  the  progress  of  modern  science.  It  is  the  bes 
work  on  Diseases  of  the  Liver  in  any  language.- 
London  Med.  Times  and  Gazette,  June  27,  iS57. 

This  work,  now  the  standard  book  of  reference  o 
the  diseases  of  which  it  treats,  has  been  carefull 
revised,  and  many  new  illustrations  of  the  views  t 
the  learned  author  added  in  the  present  edition.- 
Dublin  Quarterly  Journal,  Aug.  1857. 


BY  THE  SAME  AUTHOR. 


^?ttJ?S.J?a?S^?^^  DISEASES  AND  FUNCTIONAL  DISORDERS  01 

irtn.  biUiVlAOH.    In  one  neat  octavo  volume,  extra  cloth.    $150. 

BUCKNILL  (J.  C),   M.  D., 

Medical  Superintendent  of  the  Devon  County  Lunatic  Asylum  f  and 
DANIEL   H.   TUKE,    M.  D., 

Visiting  Medical  Officer  to  the  York  Retreat 

A  MANUAL  OF   PSYCHOLOGICAL   MEDICINE;   containing  the  History 

JNosoogy,  Description,  Statistics,  Diagnosis,  Pathology,  and  Treatment  of  INSANITY.     Wit} 

a  Plate.     In  one  handsome  octavo  volume,  of  536  pages.     S3  00. 

The  increase  of  mental  disease  in  its  various  forms,  and  the  difficult  questions  to  whicli  it  i; 
constantly  giving  rise,  render  the  subject  one  of  daily  enhanced  interest,  requiring  on  the  part  o 
the  physician  a  constantly  greater  familiarity  with  this,  the  most  perplexing  branch  of  his  profes- 
sion At  the  same  time  there  has  been  for  some  years  no  work  accessible  in  this  country,  present- 
ing the  results  of^  recent  mvestigalions  in  the  Diagnosis  and  Prognosis  of  Insanity,  and  the  greath 
.r/hrf,h™'>  i  ■  'J-eatment  which  have  done  so  much  in  alleviating  the  condition  or  restoring 
the  health  of  the  insane.  To  fill  this  vacancy  the  publishers  present  this  volume,  assured  thai 
the  distinguished  reputation  and  experience  of  the  authors  will  entitle  it  at  once  to  the  confidence 
^t  °'^ff.  ^l"'''^.'"  and  practitioner.  Its  scope  may  be  gathered  from  the  declaration  of  the  authors 
that  "their  aim  has  been  to  supply  a  text  book  which  may  serve  as  a  guide  in  the  acquisition  oi 
*uch  Knowledge,  sufficiently  elementary  to  be  adapted  to  the  wants  of  the  student,  and  sufficientlv 
modern  m  its  views  and  explicit  in  its  teaching  to  suffice  for  the  demands  of  the  practitioner." 

BENNETT   (J.    HUGHES),    M.  D.,    F.  R.  S.  E. 

Professor  of  Clinical  Medicine  in  the  University  of  Edinburo-h   &c 

'^??=tF^'^^^^^^^  ^^^  TREATMENT  OF  PULMONARY  TUBERCU- 
LOSIS, and  on  the  Local  Medication  of  Pharyngeal  and  Laryngeal  Diseases  frequently  mistakeu 
for  or  associated  with,  Phthisis.    One  vol.  8vo.,extra  cloth,  with  wood-cuts,    pp  130     $1  25 

BENNETT  (HENRY),  M.  D. 
A  PRACTICAL  TREATISE  ON  INFLAMMATION  OF  THE  UTERUS 

ITS  CERVIX  AND  APPENDAGES,  and  on  its  connection  with  Uterine  Disease  To  which 
IS  added,  a  Review  of  the  present  stale  of  Uterine  Pathology.  Fifth  American,  from  the  third 
Lnglish  edition.     In  one  octavo  volume,  of  about  500  pages,  extra  cloth.  $2  00.     (Now  Readv  ! 


The  ill  health  of  the  author  having  prevented  the  promised  revision  of  this  work,  the  ore^pntJ 
edition  is  a  reprint  of  the  last,  without  alteration.  As  the  volume  has  been  for  some  time  out'ofi 
print,  gentlemen  desiring  copies  can  now  procure  them. 

BOWMAN  (JOHN    EJ,  M.D. 
PRACTICAL   HANDBOOK   OF    MEDICAL    CHEMISTRY.     Second  Ame 

ncan,  from  the  third  and  revised  English  Edition.     In  one  neat  volume,  royal  12mo    extra  cloth 
with  numerous  illustrations,    pp.  288.     $125.  )'"yo-i  x^mo.,  extra  ciotfi, 


INTRODUCTION    TO    PRACTICAL    CHEMISTRY,    INCLUDING   ANA- 

LYSIS.    Second  American,  from  the  second  and  revised  London  edition.     Withnumerousillus- 
trations.    In  one  neat  vol.,  royal  12mo.,  extra  cloth,    pp.  350.    $1  25.  ^in numerous iims 


BEALE  ON  THE  LAWS  OF  HEALTH  IN  RE- 
LATION TO  MIND  AND  BODY.  A  Series  of 
Letters  from  an  old  Practitioner  to  a  Patient.  In 
one  volume,  royal  12mo.,  extra  cloth,     pp.  296. 

80  cents. 

BUSHNAN'S  PHYSIOLOGY  OF  ANIMAL  AND 
VEGETABLE  LIFE;  a  Popular  Treatise  on  the 
Functions  and  Phenomena  of  Organic  Life.  In 
one  handsome  royal  ]2mo.  volume,  extra  cloth, 


^^^l^rf  ^^S^X^^  ETIOLOGY,  PATHOLOGY, 
^^>P  ^l^r^il.f^^'^  OF  FIBRO-BRONCHI- 
TIS  AND   RHEUMATIC    PNEUMONIA.      In 

one  8vo.  volume,  extra  cloth,     pp.  150.     $1  25. 
BLOOD    AND    URINE  (MANUALS   ON)      BY 
JOHN    WILLIAM    GRIFFITH,     G.     OWEN 
REESE,  AND   ALFRED   MARKWICK.      One 
thick   volume,  royal    12mo.,   extra  cloth,   with 

, , ,        plates,    pp.460.     $125.  ' 

With  over  100  illustrations,    pp.234.    80  cents.       I  BRODIE'S    CLINICAL   LECTURES   ON    SUR- 
GERY.   Ivol.Svo.  cloth.    350  pp.    $125. 


BARCLAY  (A.  W.),  M .  D., 

Assistant  Physician  to  St.  George's  Hospital,  &c. 

A  MANUAL  OF  MEDICAL  DIAGNOSIS ;   being  an  Analysis  of  the  Signs 

and  Symptoms  of  Disease.    la  one  neat  octavo  volume,  extra  cloth,  of  424  pages.   $2  00.    {Lately 
issued.) 

Of  works  exclusively  devoted  to  this  important  i  The  task  of  composing  such  a  work  is  neither  an 
branch  our  profession  has  at  command,  eompara-  easy  nor  a  light  one  ;  but  Dr.  Barclay  has  performed 
tivelv  but  few,  and.  therefore,  in  the  publication  of  it  in  a  manner  which  meets  our  most  unqualihed 
the  present  work,  Messrs.  Blanchard  &  Lea  have  '  approbation.  He  is  no  mere  theorist;  he  knows  his 
conferred  a  great  favor  upon  us.  Dr.  Barclay,  from  1  work  thoroughly,  and  m  attempting  to  perform  it, 
havin"- occupied,  for  a  long  period,  the  position  of  has  not  exceeded  his  powers.— £ri«is/iMe(i.JoMr/iai, 
Medieval  Registrar  at  St.  George's  Hospital,  pos-    Dec.  5,  1857. 

,  ,  . r„.  „ — „„»„!,„„„„»;„. 1  ,»i;_  Weventure  to  predict  that  the  work  will  be  de- 
servedly popular,  and  soon  become,  like  Watson's 
Practice,  an  indispensable  necessity  to  the  practi- 
tioner.—lY.  A.  Med.  Journal,  April,  1858. 

An  inestimable  work  of  reference  for  the  young 
practitioner  and  student.— iVas/ii)iiZe  Med.  Journal, 
May,  1858. 

We  hope  the  volume  will  have  an  extensive  cir- 
culation, not  among  students  of  medicine  only,  but 
worK,  uiai,  iroi.1  lus  sys-  practitioners  also.  They  will  never  regret  a  faith- 
tematic' manner  of  arrangement,  his  work  is  one  of  ful  study  of  itspages.-CwcmnoMian,ce«,Mar.  5b. 
the  best  works  "  for  reference"  in  the  daily  emer-  ^jj  important  acquisition  to  medical  literiture. 
gencies  of  the  practitioner,  with  which  we  are  ac-  it  is  a  work  of  high  merit,  both  from  the  vast  ira- 
.   .    J     u...   „..  ^u„  „„„„  t\^.^  «ro  ,.,r,niH  rennm.  I  p(,f  ^j^^gg  gf  tlic  subject  upou  wluch  It  treats,  and 


AND    SCIENTIFIC    PUBLICATIONS. 


1>±CUH^C11      it\^giaiiui      «...     ..-.-.       O- 1 7      I         , 

sessed  advantages  for  correct  observation  and  reli 
able  conclusions,  as  to  the  significance  of  symptoms, 
which  have  fallen  to  the  lot  of  but  few,  either  in 
his  own  or  any  other  country.  He  has  carefully 
systematized  the  results  of  bis  observation  of  over 
twelve  thousand  patients,  and  by  his  diligence  and 
judicious  classification,  the  profession  has  been 
presented  with  the  most  convenient  and  reliable 
work  on  the  subject  of  Diagnosis  that  it  has  been 
our  good  fortune  ever  to  examine,-  we  can,  there- 
fore, say  of  Dr.  Barclay's  work,  that,  from  his  sys 


's'oulh7rriMed.'and'surg.Journ.,Ua.tch,\B^.  |  so"ri'chry"deserves  -  that  place  in  every  medical 

To  give  this  information,  to  supply  this  admitted    library  which  it  can  so  well  ^.AoTO..-Peninsular 
deficiency,  is  the  object  of  Dr.  Barclay's  Manual.  ]  Medical  Journal,  Sept.  1858. 


BARLOW   (GEORGE  H.),   M.D. 

Physician  to  Guy's  Hospital,  London,  &c. 

A  MANUAL  OF  THE  PRACTICE  OF  MEDICINE.    With  Additions  by  D. 

F.  CoNDiE,  M.  D.,  author  of"  A  Practical  Treatise  on  Diseases  of  Children,"  &c.    In  one  hand- 
some octavo  volume,  leather,  of  over  600  pages.     $2  75 


We  recommend  Dr.  Barlow's  Manual  in  the  warm 
est  manner  as  a  most  valuable  vade-mecum.  We 
have  had  frequent  occasion  to  consult  it,  and  have 
found  it  clear,  concise,  practical,  and  sound.  It  is 
eminently  a  practical  work,  containing  all  that  is 
essential,  and  avoiding  useless  theoretical  discus- 
sion The  work  supplies  what  has  been  for  some 
time  wanting,  a  manual  of  practice  based  upon  mo- 
dern discoveries  in  pathology  and  rational  views  of 
treatment  of  disease.  It  is  especially  intended  for 
the  use  of  students  and  junior  practitioners,  but  it 


will  be  found  hardly  less  useful  to  the  experienced 
physician.  The  American  editor  has  added  to  the 
work  three  chapters— on  Cholera  Infantum,  Yellow 
Fever,  and  Cerebro-spinal  Meningitis.  These  addi- 
tions, the  two  first  of  whicli  are  indispensable  to  a 
work  on  practice  destined  for  the  profession  in  this 
country,  are  executed  with  great  judgment  and  fi- 
delity by  Dr.  Condie,  who  has  also  succeeded  hap- 
pily in  imitating  the  conciseness  and  clearness  of 
style  which  are  such  agreeable  characteristics  ol 
the  original  book.— Boston  Med.  and  Surg.  Journal. 


BARTLETT  (ELISHA),  M.  D. 
TTTT^   mSTOHY    DIAaNOSIS,  AND  TREATMENT  OF  THE  FEVERS 

0?T?E  UNITED  STATES  A  new  and  revised  edition.  By  Alonzo  Clark,  M.  D  Prof. 
Ktho^ogy  id  P-Sctl  Medicine  in  the  N.  Y.  College  of  Physicians  and  Surgeons,  &c.  La 
one  octavo  volume,  of  SIX  hundred  pages,  extra  cloth.    Price  $3  00.  ^,    „     .,       ,    , 

lTrsthebestworko;feverswhichh^^^^ 

^a-Tf^tvaTeThiSrof  a^'X^n^^^^^^^^^^  1  tion  of  tl^e  science  as  it  exists  at  the  present^ua^y 


LTupoI  tVe  subject  mthe  bid  and  New  World,  so 
thlt  the  doctrines  advanced  are  brought  down  to  the 
latest  date  in  the  progress  of  this  department  of 
Medical  Science.— London  Med.  Times  and  Gazette, 
May  2,  1857. 

This  excellent  monograph  on  febrile  disease,  has 
stood  deservedly  high  since  its  first  publication  It 
will  be  seen  that  it  has  now  reached  its  fourth  edi- 
tion under  the  supervision  of  Prof.  A.  Clark,  a  gen- 
tleman who,  from  the  nature  of  his  studies  and  pur- 
suits, is  well  calculated  to  appreciate  and  discuss 
the  many  intricate  and  difficult  questions  in  patho- 


in  regard  to  this  class  of  diseases.— So«iAer»  3Ied. 
and  Surg.  Journal,  Mar.  1857. 

It  is  a  work  of  great  practical  value  and  interest, 
containing  much  that  is  new  relative  to  the  several 
diseases  of  which  it  treats,  and,  with  the  additions 
of  the  editor,  is  fully  up  to  the  times.  The  distinct- 
ive features  of  the  different  forms  of  fever  are  plainly 
and  forcibly  portrayed,  and  the  lines  of  demarcation 
carefully  and  accurately  drawn,  and  to  the  Ameri- 
can practitioner  is  a  more  valuable  and  safe  guide 
than  any  work  on  fever  extant— 0/ito  Med.  and 
Surg.  Journal,  May,  1857. 


BROWN    {ISAAC    BAKER), 

Sur<reon- Accoucheur  to  St.  Mary's  Hospital,  &c. 

ON  SOME  DISEASES^OF  WOMEN  ADMITTJNa^^^^^^^ 

MENT.    Withhandsome  illustrations.    On^^^^^^^  ^^^^^  ^^^^^„^. 

tio^'inreTp^r\^tfr^tI?^rofsun!ifS^^^^ 

iion^m  "-".«  "l"  .,.  .  f„.^oiB=!.rpr)eeuliarlv  subject.       ,,t„  i,o„»  „r.  hpsitat  oninrecomm 


tion  in  the  operative  ircabiiio"-  "'"-;-;<,.. 
and  iniuries  to  which  females  are  peculiarly  subject 
We  ein  truly  say  of  his  work  that  it  ^l  an  important 
addition  to  obstetrical  literature  ^h.  operatu^e 
suggestions  and  contrivances  ^(^ich  Mr  Brown  de 
scribes,  exhibit  much  practical  sagacity  and  skill, 


We  have  no  hesitation  in  recommending  this  book 
to  fte  careful  attention  of  all  surgeons  who  makfl 
female  complaints  a  partof  their  study  and  prccti-ja. 
—Dublin  Quarterly  Journal. 


BLANCHARD  &  LEA'S   MEDICAL 


CARPENTER  (WILLIAM    B.),   M.  D.,  F.  R.  S.,  &.C. 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  Lon'don 

PEINCIPLES  OP  HUMAN  PHYSIOLOGY:  with  their  chief  aDi^lioatinn,  i 

Psychology,  Pathology  Therapeutics,  Hygiene,  and  ForCicLdiSne  A  newiS  n  fro 
the  last  and  revised  London  edition.  With  nearly  three  hundred  iU,i<tr^,i^..  Z^,^  J  , , 
tions,  by  Francis  Gurney  Smith,  M.  D.,  ProfSor  of  thriSue;  of  ]^^^^^^  ^^'^ 

vania  Medical  College  &c.  In  one  very  large  and  beautiJuVoctro  vowtSXun Sie  h^^^^^ 
large  pages,  handsomely  printed  and  strongly  bound  in  leather,  with  raised  bands      $4  25 
In  the  preparation  of  this  new  edition,  the  author  has  spared  no  labor  to  render  it  as  heretofnJ 
a  complete  and  lucid  exposition  of  the  most  advanced  condition  of  L  importanKublT  % 
amount  of  the  additions  required  to  effect  this  object  thoroughly,  joined   o  tKrmer  &  ;i  J^ 
SLri""r '  P^«^^"t"'§^  objections  arising  from  the  unwieldy  bulk  of  the  work  he  has  omitTed  a^  ' 
those  portions  not  bearing  directly  upon  Human  Physiology,  designinnoncorporate  them  1  '' 
his  forthcoming  Treatise  on  General  Physiology.    As  a  full  and  accurals  tex"-book  on  the  Phv  f 

^^X^de^n^tSA^sir^hl'lLr/wLS^^^^ 

guished  favor  whi4  it  has  so  long  enjoyed!^   The'  adtolot/^fTrof^Sm  tl'^iir^^ToSd  ?o  fu2 

whatever  may  have  been  want  ng  to  the  American  student   whil^th^    nt.  i     »  )  PP'5 

wfrKTelf  cl^ill^ed^rr  .""rlte^ZCX-  I  W^.^X^irh o^^*^  ^7 '?  '^  superfluous] : 
rally,  both  in  this  country  and  England,  as  the  most  the  nnthi  °r  '  !^''^7"',  *''^*  '"  ^^'^  ^'''tio''  * 
valuable  compendium  on  the  subjSct  of  phvsL™/v    forV.r^n^^  remodelled  a  large  portion  of  the  ' 

in  our  language.   This  distinction  it  owes^to^S^    te  es^'esnec  aHv  if  tW.v:^''''^f  "1^''. '""""'"  "^  '''"^ 

may  almost  be  considered  a  new  work.    We  need  '"°®'  complete  work  on  the  science  in  our 

hardly  say,  in  concluding  this  brief  notice,  that  while  "^"ffuage.— ^m.  Med.  Journal.    ■ 

the  work  is  indispensable  to  every  student  of  medi-        The  most  complete  work  now  extant  in  our  Inn 

eme  in  this  country,  it  will  amply  repay  the  practi-  guage.— iV.  O.  3Ied.  Register 

tioner  for  its  perusal  by  the  interest  and  value  of  its        The  best  text  hoolr  ir,  h.„  Io„„ 

contents.-£o..o«  3Ied.  and  Surg.  Journal.  tensive  subJec^!lSrf^^  mJ'SF  ""^   '''''  '^■ 

kL'p  pa^^^e^wfthlrrl'^i^d^rgTowt ''reil^e'^V'pU"  oflto^'ne 'f^^^""  °' ""^,  '''''fP'  -"  ""^^P^  ^^^o 

siology .     Nothing  need  be  said  in  fts  praTse   for  i^^  th™,?,f '  ^^  'in^'o^f'y  and  for  some  time  awaited 

merits  are  universally  known  ,  we  have  nothing  to  Human  pSvsEv^  'r-  T  '''*"T  "^  Carpenter's 

»mr  rif  itc,  ri»f„„t„   f,:,  n l^ _          ummug  [o  «uman  Jr'n>siology.    His  former  editions  have  for 


eay  of  Us  defects,  for  they  only  appear  where  the 
science  of  which  it  treats  is  incomplete.— TTes^ern 
Lancet. 

The  most  complete  exposition  of  physiology  which 
any  language  can  at  present  give.— i!ri2.  and  For 
Med.-Chirurg.  Review. 

The  greatest,  the  most  reliable,  and  the  best  book 
on  the  subject  which  we  know  of  in  the  Enelish 
language. — Stethoscope. 


many  years  been  almost  the  only  text-book  on  Phy- 
siology in  al  our  medical  schools,  and  its  circula- 
tion among  the  profession  has  been  unsurpassed  bv 
any  work  m  any  department  of  medical  science 

It  IS  quite  unnecessary  for  us  to  speak  of 'this 
work  as  its  merits  would  justify.  The  mere  an- 
nouncement of  its  appearance  will  afford  the  highest 
pleasure  to  every  student  of  Physiology,  while  its 
perusa  ^vlll  be  of  infinite  service  in  'advancing 
physiological  science— OAio  Med.  and  Surg.  Journ. 


BY  THE   SAME   AUTHOR. 

^H^'^^'^.^^O'^  COMPARATIVE  PHYSIOLOaY.    New  American   from 

This  book  should  not  only  be  read  but  thoroughly 
studied  by  every  member  of  the  profession.  None 
are  too  wise  or  old,  to  be  benefited  thereby.  But 
especially  to  the  younger  class  would  we  eordiallv 
commend  it  as  best  fitted  of  any  work  in  the  English 
language  to  qualify  them  for  the  reception  and  com- 
prehension of  those  truths  which  are  daily  being  de- 
veloped m  physiology  .—Me^iicaZ  Counsellor. 

Without  pretending  to  it,  it  is  an  encyclopedia  of 
the  subject,  accurate  and  complete  in  all  respects- 
a  truthlul  reflection  of  the  advanced  state  at  which 
the  science  has  now  amy^di.— Dublin  Quarterly 
Journalof  Medical  Science. 

A  truly  magnificent  work— in  itself  a  perfect  phv- 
fliological  siuAy.— Ranking-' s  Abstract. 

This  work  stands  without  its  fellow.  It  is  one 
few  men  in  Europe  could  have  undertaken;  it  is  one 


no  man,  we  believe,  could  have  brought  to  so  suc- 
cessful an  issue  as  Dr.  Carpenter,    ft  required  for 
Its  production  a  physiologist  at  once  deeply  read  in 
the  labors  of  others,  capable  of  taking  a  general, 
critica  ,  and  unprejudiced  view  of  those  labors,  and 
of  combining  the  varied,  heterogeneous  materials  at 
his  disposal,  so  as  to  form  an  harmonious  whole 
We  feel  that  this  abstract  can  give  the  reader  a  very 
imperfect  idea  of  the  fulness  of  this  work,  and  no 
idea  of  Its  unity,  of  the  admirable  manner  in  which 
material  has  been  brought,  from  the  most  various 
sources,  to  conduce  to  its  completeness,  of  the  lucid- 
ity of  the  reasoning  it  contains,  or  of  the  clearness 
of  language  in  which  the  whole  is  clothed.    Not  the 
profession  only,  but  the  scientific  world  at  laro-e 
must  feel  deeply  indebted  to  Dr.  Carpenter  for  this 
great  work.    It  must,  indeed,  add  largely  even  to 
his  high  reputation.— ilfedtcai  Times 


AND    SCIENTIFIC    PUBLICATIONS 


CARPENTER  (WILLIAM  B.),   M.  D.,  F.  R.  S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

EE  MICROSCOPE  AND  ITS  REVELATIONS.      With  an  Appendix  con- 

taining  the  Applications  of  the  Microscope  to  Clinical  Medicine,  &c.  By  F.  G.  Smith,  M.  D. 
Illustrated  by  four  hundred  and  thirty-four  beautiful  engravings  on  wood.  In  one  large  and  very 
handsome  octavo  volume,  of  724  pages,  extra  cloth,  $4  00  ;  leather,  54  50. 

Dr.  Carpenter's  position  as  a  microscopist  and  physiologist,  and  his  great  experience  as  a  teacher, 
ainently  qualify  him  to  produce  what  has  long  been  wanted — a  good  text-book  on  the  practical 
,e  of  the  microscope.  In  the  present  volume  his  object  has  been,  as  stated  in  his  Preface,  "  to 
imbine,  within  a  moderate  compass,  that  information  with  regard  to  the  use  of  his  '  tools,'  which 
most  essential  to  the  working  microscopist,  with  such  an  account  of  the  objects  best  fitted  for 
s  study,  as  might  qualify  him  to  comprehend  what  he  observes,  and  might  thus  prepare  him  to 
mefit  science,  whilst  expanding  and  refreshing  his  own  mind"  That  he  has  succeeded  in  accom- 
ishing  this,  no  one  acquainted  with  his  previous  labors  can  doubt. 

The  great  importance  of  the  microscope  as  a  means  of  diagnosis,  and  the  number  of  microsco- 
sts  who  are  also  physicians,  have  induced  the  American  publishers,  with  the  author's  approval,  to 
Id  an  Appendix,  carefully  prepared  by  Professor  Smith,  on  the  applications  of  the  instrument  to 
inical  medicine,  together  with  an  account  of  American  Microscopes,  their  modifications  and 
icessories.  This  portion  of  the  work  is  illustrated  with  nearly  one  hundred  wood-cuts,  and,  it  is 
jped,  will  adapt  the  volume  more  particularly  to  the  use  of  the  American  student. 

Every  care  has  been  taken  in  the  mechanical  execution  of  the  work,  which  is  confidently  pre- 
jnted  as  in  no  respect  inferior  to  the  choicest  productions  of  the  London  press. 

The  mode  in  which  the  author  has  executed  his  intentions  may  be  gathered  from  the  following 
mdensed  .synopsis  of  the 

CONTENTS. 

^JTRODTJCTION — Hlstory  of  the  Microscope.  Chap.  I.  Optical  Principles  of  the  Microscope. 
Chap.  II.  Construction  of  the  Microscope.  Chap.  III.  Accessory  Apparatus.  Chap.  IV. 
Management  of  the  Microscope  Chap.  V.  Preparation,  Mounting,  and  Collection  of  Objects. 
Chap.  VI.  Microscopic  Forms  of  Vegetable  Life— Protophytes.  Chap.  VII.  Higher  Cryptoga- 
mia.  Chap.  VIII.  Phanerogamic  Plants.  Chap.  IX.  Microscopic  Forms  of  Animal  Life— Pro- 
tozoa—Animalcules.  Chap.  X.  Foraminifera,  Polycystina,  and  Sponges.  Chap.  XI.  Zoophytes. 
Chap.  XII.  Echinodermata.  Chap.  XIII.  Polyzoa  and  Compound  Tunicata.  Chap.  XIV. 
Molluscous  Animals  Generally.  Chap.  XV.  Amiulosa.  Chap.  XVI.  Crustacea.  Chap.  XVII. 
Insects  and  Arachnida.  Chap.  XVIII.  Vertebrated  Animals.  Chap.  XIX.  Applications  of  the 
Microscope  to  Geology.  Chap.  XX.  Inorgauic  or  Mineral  Kingdom— Polarization.  Appendix. 
Microscope  as  a  means  of  Diagnosis— Injections— Microscopes  of  American  Manufacture. 

Those  who  are  acquainted  with  Dr.  Carpenter's  '  medical  work,  the  additions  by  Prof.  Smith  give  it 


irevious  writings  on  Animal  and  Vegetable  Physio 
ogy ,  will  fully  understand  how  vast  a  store  of  know- 
edge  he  is  able  to  bring  to  bear  upon  so  comprehen- 
ive  a  subject  as  the  revelations  of  the  microscope  ; 


a  positive  claim  upon  the  profession,  for  v/hich  we 
doubt  not  he  will  receive  their  sincere  thanks.  In- 
deed, ■we  know  not  where  the  student  of  medicine 
will  find  such  a  complete  and  satisfactory  collection 


ind  even  those  who  have  no  previous  acquaintance  j  of  microscopic  facts  bearing  upoiu  physiology  and 
vith  the  construction  or  uses  of  this  instrument,  j  practical  medicine  as  is  contained  m  Prof.  Smith's 
vill  find  abundance  of  information  conveyed  in  clear  ■  appendix;  and  this  of  itselt,  it  seems  to  us,  is  fully 
ind  simple  language.— Med.  Times  and  Gazette.  |  worUi  the  cost  of  the  volume.— LoKismHe  MeciicaJ 
Although  originally  not  intended  as  a  strictly  1  -Bemew,  Nov.  Ib56. 

BY   THE  SAME   AUTHOR. 

ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO- 
LOGICAL ANATOMY.  Second  American,  from  a  new  and  revised  London  edition.  With 
one  hundred  and  ninety  illustrations.  In  one  very  handsome  octavo  volume,  leather,  pp.  56b. 
$3  00. 

In  publishing  the  first  edition  of  this  work,  its  title  was  altered  from  that  of  the  London  volume, 
w  the  substitution  of  the  word  "  Elements"  for  that  of  "  Manual,"  and  with  the  author's  sanction 
:he  title  of  "Elements"  is  still  retained  as  being  more  expressive  of  the  scope  of  the  treatise. 


To  say  that  it  is  the  best  manual  of  Physiology 
ttow  before  the  public ,  would  not  do  sufficient  justice 
to  the  aathox. —B-uffalo  Medical  Journal. 

In  his  former  works  it  would  seem  that  he  had 
exhausted  the  subject  of  Physiology.  In  the  present, 
he  gives  the  essence,  as  it  were,  ofthewhole. — N.  Y. 
Journal  of  Medicine. 


Those  who  have  occasion  for  an  elementary  trea- 
tise on  Physiology,  cannot  do  better  than  to  possess 
themselves  of  the  manualof  Dr.  Carpenter.— ilfedicaJ 

Examiner . 

The  best  and  most  complete  expos6  of  modern 
Physiology,  in  one  volume,  extant  in  the  English 
language. — St.  Louis  Medical  Journal. 


BY  THE  SAME  AUTHOR.     (Preparing.) 

PRINCIPLES  OF   GENERAL   PHYSIOLOGY,   INCLUDING   ORGANIC 

rHFmSKV  AND  HISTOLOGY.  With  a  General  Sketch  of  the  Vegetable  and  Animal 
KSgd'^S  fZone'JSg^and  very  handsome  octavo  volume,  with  several  hundred  ^  -traUons^ 
The'subject  of  general  P/Ysiology  having  been  omitted  m^  it^:^^^ 

as  an  introduction  to  his  other  works. 

BY  THE   SAME  AUTHOR. 

A  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN  HEALTH 

AND  DIsJisENli  edition,  with  a  Preface  by  D^F.  CoKBrE,  M.  D     and  explanations  rf 
I     fcientifie  words.    In  one  neat  12mo.  volume,  extra  cloth,    pp.178.    50  cents. 


BLANCHAKD  &  LEA'S  MEDICAL 


CONDIE  (D.  FJ,  M.  D.,  &c 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILDREN     Fif 

the  pathology  and  therapeutics  of  the  maladies"Sent'to  the  L?^C    4les'of  e5.,Z.e'    a"f 

Dr.  Condie's  scholarship,  acumen,  industry,  and       — 
practical  sense  are  manifested  in  this,  as  in  all  his 
numerous  contributions  to  science.— Dr.  Holmes's 
Report  to  the  American  Medical  Association. 

Takenasa  whole,  in  our  judgment.  Dr.  Condie's 
1  realise  is  the  one  from  the  perusal  of  which  the 


practitioner  in  this  country  will  rise  with  the -reat- 
est  satisfaction— WesierraJoMmaZ  of  Medicine  and 
Surgery. 

One  of  the  best  works  upon  the  Diseases  of  Chil- 
dren in  the  English  language.— lVes2em  Lancet. 

We  feel  assured  from  actual  experience  that  no 
physician's  library  can  be  complete  without  a  copy 
of  this  work.— jy.  Y .  Journal  of  Medicine . 

A  veritable  paediatric  encyclopaedia,  and  an  honor 
to  American  medical  literature.— OAio  Medical  and 
Surgical  Journal. 

We  feel  persuaded  that  the  American  medical  pro 
fession  will  soon  regard  it  not  only  as  a  very  good 


We  pronounced  the  first  edition  to  be  the  be « 
work  on  the  diseases  of  children  in  the  Englii  ei 
language,  and,  notwithstanding  all  that  has  be<  ( 
^^xamil     ^^  ^"'^  ^<iS^tA  it  in  that  light.— Me^iic  ii 

The  value  of  works  by  native  authors  on  the  dii  j! 
eases  which  the  physician  is  called  upon  to  comba"^ 
will  be  appreciated  by  all;  and  the  work  of  Dr  Coil 
die  has  gained  for  itself  the  character  of  a  safe  guic  ''' 
for  students,  and  a  useful  work  for  consultation  b  ^ 
those  engaged  in  practice.— JV.  Y.  Med.  Times.  I 
This  is  the  fourth  edition  of  this  deservedly  popu  1' 
lar  treatise.  During  the  interval  since  the  last  edj  ai 
tion,  it  has  been  subjected  to  a  thorough  revisio 
by  the  author;  and  all  new  observations  in  th  , 
pathology  and  therapeutics  of  children  have  bee  ■ 
included  in  the  present  volume.  As  we  said  btfor«  *' 
we  do  not  know  of  a  better  book  on  diseases  of  ehil  "i 
dren,  and  to  a  large  part  of  its  recommendations  w  " 
yield  an  unhesitating  concurrence.- BMj"a/o  Med 


Dif™  nf  r^hVn  ^^',^  "Practical  Treatise  ol  t\ye\  Journal 

Uise&ses  of  ChilAxen."— American  Medical  Journal   \     p„,v.,„ti  ..-,,., 

-The  stethoscolf  ''"'  ^°°'''''  language,    nor^tcnnostof  itspredecessors.-rra«.2,i^a«i«M^d  « 

'  [ ■  1! 

CHRISTISON  (ROBERT),  M.  D..  V    P    R    S    E      A'c  i« 

^■S SfSi^?^^'  "'  Commentary' on  the' Phar;acop;fas  of  Great  BritAJ 

In  one  very  l.rge  .„d  handsome  «...-'^^^^S^^^i^:T;^\S^'^^:  «' D" 

COOPER  (BRANSBY  BJ,  F.  R.  S. 
LECTURES  ON  THE  PRINCIPLES   AND   PRACTICE   OF   SURaERY 

In  one  very  large  octavo  volume,  extra  cloth,  of  750  pages.    $3  00.  «J  u  j.burJ3.i^i . 


COOPER  ON  DISLOCATIONS  AND  FRAC- 
TURES OF  THE  JOINTS.-Edited  by  Bransby 
B.  Cooper,  F.  R.  S.,  &c.  With  additional  Ob- 
servations by  Prof.  J.  C.  Warken.  a  new  Ame- 
rican edition.  In  one  handsome  octavo  volume 
extra  cloth,  of  about  500  pages,  with  numerous 
illustrations  on  wood.    $3  25. 

COOPER  ON  THE  ANATOMY  AND  DISEASES 
OF  THE  BREAST,  with  twenty-five  Miscellane- 
ous and  Surgical  Papers.  One  large  volume,  im- 
perial 8vo.,  extra  cloth,  with  252  figures,  on  36 
plates.    $2  50. 

COOPER  ON  THE  STRUCTURE  AND  DIS- 
EASES OF  THE  TESTIS,  AND  ON  THE 
THYMUS  GLAND.  One  vol.  imperial  8vo.,  ex- 
tra  cloth,  with  177  figures  on  29  plates.    $2  00. 


COPLAND  ON  THE  CAUSES,  NATURE  4.ND 
TREATMENT  OF  PALSY  AND  APOPLEXY 

In  one  volume,  royal  12mo.,  extra  cloth,  pp  326* 
eO  cents.  "^ 

CLYMER  ON  FEVERS;  THEIR  DIAGNOSIS 
PATHOLOGY,  AND  TREATMENT  In  one 
octavo  volume,  leather,  of  600  pages.    $1  50. 

^np°™Tr^l^'^!^^^  ON  THE  DISEASES 
Ot  FEMALES,  and  on  the  special  Hygiene  of 
their  Sex.  Translated,  with  many  Notes  and  Ad- 
ditions, by  C.  D.  Meigs,  M.  D.  Second  edition, 
revised  and  improved.  In  one  large  volume,  oc- 
tavo, leather,  with  numerous  wood-cuts.  pp.  720. 


CARSON  (JOSEPH),  M.  D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Pennsylvania 

SYNOPSIS  OF  THE  COURSE  OF  LECTURES  ON  MATERIA 'mF DTP  A 

AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania     Second  1^  Ml!.DICA 
tion.    In  one  very  neatoctavovolume,extracIo^th,  ofsOsS!    $]  50?  '"''  ^" 

CURLING    (T.    B.),    F.R.S., 

Surgeon  to  the  London  Hospital,  President  of  the  Hunterian  Society  &c 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  TESTTs'  RPFT?ma 

TIC  CORD,  AND  SCROTUM.    Second  American,  from  tl  ifofd  and  Llr^^H-^r^ 
tton.    In  one  handsome  octavo  volume,  extra  cloth.  withTuL^VoSttrllty^^p.lt'^'a^t 


AND    SCIENTIFIC    PUBLICATIONS. 


CHURCHILL  (FLEETWOOD),  M.D.,  M.  R.  I.  A. 
N  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.     A  new  American 

from  the  fourth  revised  and  enlarged  London  edition.  With  Notes  and  Additions,  by  D.  Francis 
CoNDiE,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Children,"  &c.  With  194 
illustrations.  In  one  very  handsome  octavo  volume,  leather,  of  nearly  700  large  pages.  $3  50. 
[Noto  Ready,  October,  1860.) 

This  work  has  been  so  long  an  established  favorite,  both  as  a  text-book  for  the  learner  and  as  a 
iable  aid  in  consultation  lor  the  practitioner,  that  in  presenting  a  new  edition  it  is  only  necessary 
call  attention  to  the  very  extended  improvements  which  it  has  received.  Having  had  the  beneiit 
two  revisions  by  the  author  since  the  last  American  reprint,  it  has  been  materially  enlarged,  and 
'.  Churchill's  well-known  conscientious  industry  is  a  guarantee  that  every  portion  has  been  thq- 
uo-hly  brought  up  v/ith  the  latest  results  of  European  investigation  in  all  departments  of  the  sci- 
ce  and  art  of  obstetrics.  The  recent  date  of  the  last  Dublin  edition  has  not  left  much  of  novelty 
r  the  American  editor  to  introduce,  but  he  has  endeavored  to  insert  whatever  has  since  appeared, 
o-ether  with  such  matters  as  his  experience  has  shown  him  would  be  desirable  for  the  American 
adent   including  a  large  number  of  illustrations.     With  the  sanction  of  the  author  he  has  added 

the  form  of  an  appendix,  some  chapters  from  a  little  "Manual  for  Midwives  and  Nurses,"  re- 
■ntlv  issued  by  Dr.  Churchill,  believing  that  the  details  there  presented  can  hardly  fail  to  prove  ot 
Ivantac^e  to  the  junior  practitioner.  Tne  result  of  all  these  additions  is  that  the  work  now  con- 
ins  fuTly  one-half  more  matter  than  the  last  American  edition,  with  nearly  one-half  more  lUus- 
ations,  so  that  notwithstanding  the  use  of  a  smaller  type,  the  volume  contains  almost  two  hundred 
iges  more  than  before.  .  ,      .     ,  ■         <•   i  i 

No  effort  has  been  spared  to  secure  an  improvement  m  the  mechanical  execution  ot  tlie  work 
rual  to  that  which  the  text  has  received,  and  the  volume  is  confidently  presented  as  one  of  the 
Ind^omest  that  has  thus  far  been  laid  before  the  American  profession;  while  the  very  low  price 

which  it  is  offered  should  secure  for  it  a  place  in  every  lecture-room  and  on  every  office  table. 
A  better  book  in  which  to  learn  these  important        The  most  popular  work  on  midwifery^ ever  issued 

lints  we  have  not  met  than  Dr.  Churchill's.   Every "'      '  " "" 

ige  of  it  is  full  of  instruction  ;  the  opinion  of  all 
Titers  of  authority  is  given  on  questions  of  difii- 
ilty,  as  well  as  the  directions  and  advice  of  the 
lamed  autiior  himself,  to  which  he  adds  the  result 
=■  statistical  inquiry,  putting  statistics  in  their  pio  ■ 
er  place  and  giving  them  their  due  weight,  and  no 
lore  We  have  never  read  a  book  more  free  from 
rofessional  jealousy  than  Dr.  Churchill's.  It  ap- 
ears  to  be  written  with  the  true  design  of  a  book  on 
ledieine,  viz  :  to  give  all  that  is  known  on  the  sub- 
let of  which  he  treats,  both  theoretically  and  prac- 
cally,  and  to  advance  such  opinions  of  his  own  as 
e  believes  will  benefit  medical  science,  and  insure 
le  safety  of  the  patient.  We  have  said  enough  to 
onvey  to  the  profession  that  this  book  of  Dr.  Chur- 
hill's  is  admirably  suited  for  a  book  of  reference 
jr  the  practitioner,  as  well  as  a  text-book  for  the 
tudent,"and  we  hope  it  may  be  extensively  pur- 


hased   amongst  our  readers.     _- 

trongly  recommend  it.  — Dublin  Medical   rress, 

una  20,  1860. 

To  bestow  praise  on  a  book  that  has  received  such 
larked  approbation  would  be  superfluous.  We  need 
nly  say,  therefore,  that  if  the  first  edition  was 
houirht  worthy  of  a  favorable  reception  by  the 
nedical  public,  we  can  confidently  affirm  that  this 
vill  be  found  much  more  so.  The  lecturer,  the 
ractitioner,  and  the  student,  may  all  have  recourse 
0  its  pages,  and  derive  from  their  perusal  much  in- 
prest  and  instruction  in  everything  relating  to  theo- 
etical  and  practical  midwifery.— DitSZin  Quarterly 
Tournal  of  Medical  Science. 


'rem  the  American  press.— C^arZesion  Med.  Journal. 

Were  we  reduced  to  the  necessity  of  having  but 
me  work  on  midwifery,  and  permitted  to  choose, 
ive  would  unhesitatingly  take  Churchill.— W^esJers 
Med.  and  Surg.  Journal. 

It  is  impossible  to  conceive  a  more  useful  and 
slegant  manual  than  Dr.  Churchill's  Practice  of 
\Iidwifery. — Provincial  Medical  Journal. 

Certainly,  in  our  opinion,  the  very  best  work  on 
he  subject  which  exists.- iV.  Y.  Annalist. 

No  work  holds  a  higher  position,  or  is  more  de- 
serving of  being  placed  in  the  hands  of  the  tyro, 
the  advanced  student,  or  the  practitioner.— Medicas 
Examiner. 

Previous  editions,  under  the  editorial  supervision 

of  Prof    R.  M.  Huston,  have  been  received  with 

■     ,     „„,      marked  favor,  and  they  deserved  it;  but  this,  re- 

e  extensively  pur-  '^  j^^^  jj^^^jj  edition,  carefully 

To  them  we  most    V  hrm,„ht  „n  hv  the  author  to  the  nresent 


A  work  of  very  great  merit,  and  such  as  we  can 
!!onfidently  recommend  to  the  study  of  every  obste- 
ric  practitioner . — London  Medical  Gaze  tte . 
1  This  is  certainly  the  most  perfect  system  extant. 
'[t  is  the  best  adapted  for  the  purposes  of  a  text- 
book, and  that  which  he  whose  necessities  confane 
lim  to  one  book,  should  select  in  preference  to  all 
':)thers. Southern  Medical  and  Surgical  Journal. 

BY   THE  SAME  AUTHOR 


UilULCU    HUiii     o.    v^ijr      i".v^    -^ ,     -  w 

revised  and  brought  up  by  the  author  to  the  present 
time,  does  present  an  unusually  accurate  and  able 
exposition  of  every  important  particular  embraced 
in  the  department  of  midwifery.  *  *  The  clearness^ 
directness,  and  precision  of  its  teachings,  togetlier 
with  the  great  amount  of  statistical  research  which 
its  text  exhibits,  have  served  to  place  it  already  m 
the  foremost  rank  of  works  in  this  department  of  re- 
medial science.— iV.  O.  Med.  and  Surg.  Journal. 

In  our  opinion,  it  forms  one  of  the  best  if  not  the 
very  best  text-book  and  epitome  of  obstetric  science 
which  we  at  present  possess  in  the  English  l&n- 
gaa^ge.— Monthly  Journal  of  Medical  Science. 

The  clearness  and  precision  of  style  in  which  it  is 
written,  and  the  greatamountof  statistical  research 
which  it  contains, have  served  to  place  it  mthe  first 
rank  of  works  in  this  departmentof  medical  science. 
—N.  y.  Journal  of  Medicine. 


Few  treatises  will  be  found  better  adapted  as  a 
text-book  for  the  student,  or  as  a  manual  for  the 
frequent  consultation  of  the  young  practitioner.— 
American  Medical  Journal. 
{Lately  PiMished.) 


ON  THE  DISEASES  OF  INFANTS  AND  CHILDREN.     Second  American 

whileevWportionof  the  volume  has  been  s^^^^^^  ^^  ^^^^^^^     ^^^^.^^ 

American  editor  have  been  directed  to  supply  ng  such  im^^^^^  ^^^^^  ^^^^^^ 

to  this  country  as  might  ^aje  ^P^J^^^^.^Xe  w^^  accessible  to  the  Ame- 

S^^Iir""^^^^^^  re^oflhrpage  these  veiy  extensive  additions  have 
beTn  accommodated  without  unduly  increasing  the  size  of  the  work. 

ESSAYS  ON  THE  PUERPErIl  FEvSrAND  OTHER  DISEASES  PE- 


10 


BLANCHARD    &    LEA'S    MEDICAL 


CHURCHILL  (FLEETWOOD),    M.D.,  M    R    I    A 


ON  THE  DISEASES  OF  WOMEN;  taciudmg  ihoTe'of  fte^lnf/and  ChU. 

ro»  .ll.Mrat,ons     I„  one  large  and  handsome  octavo  volume,  leather'of  7^  p°ges.^3  oS 
w  „ch  ,he  volume  has  undergone,  ^.hile  ,he  prioe  ha.  IJ„  tepTaf  Ikt  ?or™rvery  hide  afe'fa  I! 


It  comprises,  unquestionably,  one  of  the  most  ex- 
act and  comprehensive  expositions  of  the  present 
state  of  medical  knowledge  in  respect  to  the  diseases 
of  women  that  has  yet  been  published.— 4«w.  Journ 
Med.  Sciences,  July,  1857. 

This  work  is  the  most  reliable  which  we  possess 
on  this  subject;  and  is  deservedly  popular  with  the 
profession.— C/iarZesiora  Med.  Journal,  July,  1857. 

We  know  of  no  author  wlio  deserves  that  appro- 
f?ation,  on  "the  diseases  of  females,"  to  the  same 


extent  that  Dr.  Churchill  does.  His,  indeed,  is  tl" 
only  thorough  treatise  we  know  of  on  the  subjee  " 
and  It  may  be  commended  to  practitioners  and  sti" 

S4®  '\t'^  masterpiece  in  its  particular  dopartmei) " 
—Iht  Western  Journal  of  Medicine  and  Surgery. 

As  a  comprehensive  manual  for  students,  or  i„ 
work  of  reference  for  practitioners,  it  surpasses  ar ",, 
other  that  has  ever  issued  on  the  same  subject  fro  s 
the  British  press.- DkJZjw  Quart.  Journal.  \, 

le 
ie 
:i 


DICKSON   (S.    H.),    M.  D,, 
Professor  of  Practice  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia 

ELEMENTS  OF  MEDICINE;   a  Compendious  View  of  Patholosy  and  Then, 

peutics,  or  the  History  and  Treatment  of  Diseases.     Second  edition,  revised.    Iii  one  lar-e  an!' 
handsome  octavo  volume,  of  750  pages,  leather.     $3  75.     ^Just  Issued.)  "         f 


.v,T  .1^^    ^^  demand  which  has  so  soon  exhausted  the  first  edition  of  this  work,  sufficiently  show 
that  the  author  was  not  mistaken  in  supposing  that  a  volume  of  this  character  was  needed— a 
elementary  manual  of  practice,  which  should  present  the  leading  principles  of  medicine  with  th 
practical  results,  in  a  condensed  and  perspicuous  manner.     Disencumbered  of  unnecessary  deta  : 
and  fruitless  speculations,  it  embodies  what  is  most  requisite  for  the  student  to  learn,  and  at  th 
same  time  what  the  active  practitioner  wants  when  obliged,  in  the  daily  calls  of  his  profession,  t 
wLt  if  ™r™°'^  ""^  'P^'^'^^  PP'"'*-     T'^<^  ^'^'^'-  «"d  attractive  style  of  the  author  renders    h  * 
whole  easy  of  comprehension,  while  his  long  experience  gives  to  his  teachings  an  authority  everv ' 
Where  acknowledged.     Few  physicians,  indeed,  have  had  wider  opportunities  for  observation  ati  ' 
experience,  and  few,  perhaps,  have  used  them  to  better  purpose.     As  the  result  of  a  long  life  d^  ' 
ZuMul^  and  practice,  the  present  edition,  revised  and  brought  up  to  the  date  of  publication  l 
will  doubtless  maintain  the  reputation  already  acquired  as  a  condensed  and  convenient  America 
text-book  on  the  Practice  of  Medicine.  -^imciit-d.  i 


DRUITT   (ROBERT),   M.R.  C.S.,   &.c. 
THE  PRINCIPLES  AND  PRACTICE  OP  MODERN  SURGERY.     A  ne* 

and  revised  American  from  the  eighth  enlarged  and  improved  London  edition.  Illustrated  witJ ' 
four  hundred  and  thirty-two  wood-engravings.  In  one  very  handsomely  prmted  octavo  volume  ' 
leather,  of  nearly  700  large  pages.     $3  50.     (Now  Ready,  October,  1S60.)  « 

A  work  which  like  Druitt's  Surgery  has  for  so  many  years  maintained  the  position  of  a  lead  II 
iol  ^[^^1^!^  "''  "'t?'"'  f  ^^"  profession,  needs  no  special  recommendation  to  attract  attemiol 
work  .^n'tn  i^f  X    H     ^' ''  r-'^  necessary  to  state  that  the  author  has  spared  no  pams  to  keep  th< 
work  up  to  Its  well  earned  reputation  of  presenting  in  a  small  and  convenient  compass  the  lates 
condition  of  every  department  of  surgery,  considered  both  as  a  science  and  as  an  arf:  and  that  th(  I 
''^ITJ'TJ   ^^TP^'^"u^  American  editor  have  been  employed  to  introduce  whatever  novelties  mai 
have  escaped  the  author's  attention,  or  may  prove  of  service  to  the  American  practitioner      A< 
hrh^nlt'T"'  have  appeared  in  London  since  the  issue  of  the  last  American  reprint   tll^volum^ 
ha*  had  the  benefit  of  repeated  revisions  by  the  author,  resulting  in  a  very  thorough  alteration  and 
improvement.     The  extent  of  these  additions  may  be  estimated'from  the  fact  that'll  now  contaTn 
about  one-third  more  matter  than  the  previous  American  edition,  and  that  notwithstanding  the  " 
hS-eH  ^Ar         i^'P^;  'u''  PT'  ^^a^e  been  increased  by  about  one  hundred,  while  nearly  two  ' 
hundied  and  fifty  wood-cuts  have  been  added  to  the  former  list  of  illustrations  ^ 

wnrif  whvl  ""P.f°7^™.ent  Will  also  be  perceived  in  the  mechanical  and  artistical  execution  of  the  S 
ZJt'A  I}'  ^Tl^^  i!"  '^?  -^"'^  '^y''^'  °''  "''^  ^yP'^'  ^"'^  fi"*^  P'lper,  leaves  little  to  be  desired  as  ' 
^ofu^t  IcSLlf'lollie^loflsSo;!'^  ^^^^  ^°"  P"^^  ^'^^'^  ''  ^'''  '^  ^-"'^  °-  «^  ^'^  ^^-p4 


This  popular  volume,  now  a  most  comprehensive 
•work  on  surgery,  has  undergone  many  corrections, 
improvements,  and  additions,  and  the  principles  and 
the  practice  of  the  art  have  been  brought  down  to 
the  latest  record  and  observation.  Of  the  operations 
in  surgeryitisimpossible  to  speak  too  highly.  The 
descriptions  are  so  clear  and  concise,  and  the  illus- 
trations so  accurate  and  numerous,  that  the  student 
can  have  no  difficulty,  with  instrument  in  hand,  and 
book  by  his  side,  over  the  dead  body,  in  obtaininir 
a  proper  knowledge  and  sufficient  tact  in  this  much 
neglected  department  of  medical  education.— .Brt«iiA 
and  Foreign  Medico- Chirurg.  Review,  Jan.  1860 


nothing  of  real  practical  importance  has  been  omit- 
ted ;  it  presents  a  faithful  epitome  of  everything  re-  t 
lating  t )  surgery  up  to  the  present  hour.     It  is  de-  ' 
servedly  a  popular  manual,  both  witli  the  student 
and  practitioner. — Londoti  Lancet,  INov.  19,  1859.       ' 

In  closing  this  brief  notice,  we  recommend  as  cor- 
dially as  ever  this  most  useful  and  comprehensive 
hand-bojk.  It  must  prove  a  vast  assistance,  not 
only  to  the  student  of  surgery,  but  also  to  the  busy 
practitioner  wht  may  not  have  the  leisure  to  devote 
himself  to  the  study  of  more  lengthy  volumes.— 
London  Med.  Times  and  Gazette,  Otit   22,  1859. 


wr  ttenm.nvffth  h  t/"^  a"'h"r  has  entirely  re-  In  a  word,  this  eighth  edition  of  Dr.  Druitt's 
tie  var"ous"mnn  vemen?«  fn'j  ".Iv  '  incorporated  Manual  of  Surgery  islll  that  the  surgieal  studen? 
sirir^tv      On  i^TfT  ^  additions  in  modern     or   practitioner   could  desire. -i)«Wm   Quarter^ 

surgery.    On  carefully  going  over  it,  we  find  that  J  Journal  of  Med.  Sciences,  Nov.  1859.        '^'""^"^'^'* 


AND    SCIENTIFIC    PUBLICATIONS, 


11 


DALTON,   JR.   (J.   C),   M .   D. 

Professor  of  Physiology  in  the  College  of  Physicians,  New  York. 

.  TREATISE  ON  HUMAN  PHYSIOLOaY,  designed  for  the  use  of  Students 

and  Practitioners  of  Medicine.  With  two  hundred  and  fifty-four  illustrations  on  wood.  In  one 
very  beautiful  octavo  volume,  of  over  600  pages,  extra  cloth,  $4  00  ;  leatUer,  raised  bands,  $4  25. 
{Just  Issued.) 


This  system  of  Physiology,  both  from  the  ex- 
llence  of  the  arrangement  studiously  observed 
roughout  every  page,  and  the  clear,  lueid,  and  in- 
Tuctive  manner  in  which  each  subject  is  treated, 
omises  to  form  one  of  the  most  generally  received 
ass-books  in  the  English  language.  It  is,  in  fact, 
most  admirable  epitome  of  ail  the  really  important 
scoveries  that  have  always  been  received  as  mcon- 
stable  truths,  as  well  as  of  those  which  have  been 
;cently  added  to  our  stock  of  knowledge  on  this  sub- 
ct.  We  will,  however,  proceed  to  give  a  few  ex- 
acts from  the  bunk  itself,  as  a  specimen  of  its  style 
id  composition,  and  this,  we  conceive,  will  be  quite 
iffieient  to  awaken  a  general  interest  in  a  work 
■hicli  is  immeasurabl)  superior  in  its  details  to  the 
lajority  of  those  of  the  same  class  ti  which  it  be- 
)ngs.  In  its  purity  of  style  and  elegance  of  cora- 
jsition  it  m-iy  safely  take  its  place  with  the  very 
3st  of  our  English  classics;  while  in  accuracy  of 
Bscription  it  is  impossible  that  it  could  be  surpass- 
i.  In  every  line  is  beautifully  shadowed  forth  the 
ruanatioDS  uf  the  polished  scholar,  whose  retlec- 
ons  are  clothed  in  a  garb  as  interesting  as  they  are 
npressivej  vi  ith  the  one  predominant  feeling  ap- 
earing  to  pervade  the  whole — an  anxious  des,re  to 
lease  and  at  the  same  time  to  instruct. — Dublin 
uarUrly  Journ.  of  Med.  Sciences,  Nov.  1859. 

The  work  before  TIB,  however,  in  ourhumblejudg- 
lent,  is  precisely  what  it  purports  to  be,  and  will 
nswer  admirably  the  purpose  for  which  it  is  in- 
jnded.  It  is  par  exreUence,a.  text-book;  and  the 
est  text-book  in  tl,  is  department  that  we  have  ever 
een.  We  have  carefully  read  the  book,  and  speak 
f  its  merits  from  a  more  than  cursory  perusal. 

ooking  back  upon  the  work  we  have  just  finished, 
ire  must  say  a  word  concerning  the  excellence  of  its 

lustrations.  No  department  is  so  dependent  upon 
ood  illustrations,  and  those  which  keep  pace  with 
UT  knowledge  of  the  subject,  as  that  of  physiology, 
'he  wood- cuts  in  the  work  before  us  are  the  best 
sre  have  ever  seen,  and,  being  original,  serve  to 
lustrate  precisely  what  is  desired — Buffalo  Med. 
ournal,  March,  1859. 

A  hook  of  genuine  merit  like  this  deserves  hearty 
raise  before  subjecting  it  t  j  any  minute  criticism. 
Ve  are  not  prepared  to  find  any  fault  with  its  design 
ntil  we  have  had  more  time  to  appreciate  its  merits 
s  a  manual  for  daily  consultation,  and  to  weigh 
ts  statements  and  conclusions  more  deliberatelv. 
ts  excellences  we  are  sure  of;  its  defects  we  have 
et  to  discover.    It  is  a  work  highly  honorable  to 


its  author ;  to  his  talents,  his  industry,  his  training  ; 
to  the  institution  with  whieh  he  is  connecteU,  and 
to  American  science. — Boston  Med.  and  Surgical 
Journal,  Feb.  24,  1859. 

A  NEW  book  and  a  first  rate  one ;  an  original  book, 
and  one  which  cannot  be  too  highly  appreciated, 
and  which  we  are  proud  to  see  emanating  from  our 
country's  press.  It  is  by  an  author  who,  though 
young,  is  considerably  famous  for  physicdngical  re- 
search, and  who  in  this  work  has  erected  for  him- 
self an  enduring  monument,  a  token  at  once  of  his 
labor  and  his  success. — Nashville  Medical  .Journal, 
iVlarch,  1859. 

Throughout  the  entire  work,  the  definitions  are 
clear  and  precise,  the  arrangement  admirable,  the 
argument  briefly  and  well  stated,  and  the  style 
nervous,  simple,  and  concise.  Section  third,  treat- 
ing of  Reproduction,  is  a  monograph  of  unap- 
proached  excellence,  upon  this  subject,  in  the  Eng- 
lish tongue.  For  precision,  elegance  and  force  of 
style,  exhaustive  method  and  extent  of  treatment, 
fulness  of  illustration  and  weight  of  personal  re- 
search, we  know  of  no  Ameriian  contribution  to 
medical  science  which  surpasses  it,  and  the  day  is 
far  distant  when  its  claims  to  the  respectful  atten- 
tion of  even  the  best  informed  scholars  will  not  be 
cheerfully  conceded  by  all  acquainted  with  its  range 
ano  depth. — Charleston  Med.  Journal,  May,  1859. 

A  new  elementary  work  on  Human  Physiology 
liftinff  up  its  voice  in  the  presence  of  late  and  sturdy 
editions  of  Kirke's,  Carpenttr's,  Todd  and  Bow- 
man's, to  say  nothing  of  Durglison's  and  Draper's, 
should  have  something  superior  in  the  matter  or  the 
manner  of  its  utterance  in  order  to  virin  for  itself 
deserved  attention  and  a  name.  That  matter  and 
that  manner,  alter  a  candid  perusal,  we  think  dis- 
tinguish this  work,  and  v/e  are  proud  to  welcome  it 
not  merely  for  its  nativity's  sake,  but  for  its  ovsrn 
intrinsic  excellence.  Its  language  we  find  to  be 
plain,  direct,  unambitious,  and  falling  with  a  just 
conciseness  on  hypothetical  or  unsettled  questions, 
and  yet  with  sufficient  fulness  on  those  living  topics 
already  understood,  or  the  path  to  whose  solution 
is  definitely  marked  out.  It  does  not  speak  exhaust- 
i  /ely  upon  every  subject  that  it  notices,  but  it  does 
speak  suggestively,  experimentally,  and  to  their 
main  utilities.  Into  the  subject  of  Reproduction 
our  author  plunges  with  a  kind  of  loving  spirit. 
Throughout  this  interesting  and  obscure  department 
he  is  a  clear  and  admirable  teacher,  sometimes  a 
brilliant  leader.— 4ot.  Med.  Monthly,  May,  1859. 


DUNGLISON,   FORBES,   TWEEDiE,   AND   CONOLLY. 
PHE  CYCLOPEDIA  OF  PRACTICAL  MEDICINE:  comprising  Treatises  on 

the  Nature  and  Treatment  of  Diseases,  Materia  Medica,  and  Therapeutics,  Diseases  of  Women 
and  Children,  Medical  Jurisprudence,  ice.  &c.  In  four  large  super-royal  octavo  volumes,  of 
3254  double-columned  pages,  strongly  and  handsomely  bound,  with  raised  bands.  $12  00. 
*^*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed  by 
ixty-eight  distinguished  physicians,  rendering  it  a  complete  library  of  reference  for  the  country 
»ractitioner.  ^       ,         ^ 

The  most  complete  work  on  Practical  Medicine  |  titioner.  This  estimate  of  it  has  not  been  formed 
•Janf  or  at  least  iii  our  language.-£u#aZo  '  from  a  hasty  exammation  but  after  an  intimate  ac- 
xtant,    or,  at  least,   in    our    lau^ucise  m  „,,„int„nce  derived  from  frequent  consultation  of  it 


quaintance  derived  from  frequent  consultation  of  it 

during  the  past  nine  or  ten  years.     The  editors  are 

practitioners  of  established  reputation,  and  the  list 

liouci.— i'f»o.;>--^.^— ^"".  I  of  contributors  embraces  many  of  the  most  eminent 

One  of  the  most  valuable  medical  publications  of  '  professors  and  teachers  of  London,  Edinburgh,  Dub- 

-     -  1.  „r — f — „„„«  if  it.  ;r,,r.,iiiar,i«. jjjj    audGlaso'ow.    It  is,  indeed,  the  great  merit  of 

this  work  that  the  principal  articles  have  been  fur- 


^edical  and  Surgical  Journal. 

!  For  reference,  it  is  above  all  price  to  every  prac- 

itioner. — Western  Lancet. 


iie  day as  a  work  of  reference  it  is  invaluable. — 

Western  Journal  of  Medicine  and  Surgery. 


,      ,         ,  J   ..       u        „    Tiished  bv  nractitioners  who  have  not  only  devoted 

It  has  been  to  us,  both  as  learner  and  teacher   a    nishe^b^^^  ^bout  which  they 


vorkfor  ready  and  frequent  reference,  one  in  which 
aodem  English  medicine  is  exhibited  in  the  most 
idvantageous  light.— Medical  Examiner. 

We  rejoice  that  this  work  is  to  be  placed  within 
he  reach  of  the  profession  in  this  country,  it  being 
inquestionably  one  of  very  great  value  to  the  prac- 


especial  attention  to  the  diseases  about  which  they 
have  written,  but  have  also  enjoyed  opportunities 
for  an  extensive  practical  acquaintance  with  them, 
and  whose  reputation  carries  the  assurance  of  their 
competency  justly  to  appreciate  the  opinions  of 
others,  while  it  stamps  their  own  doctrines  with 
hio-h  and  just  authority. — American  Medical  Journ. 


AND  MEDICAL  TREATMENT  OF  CHILD- 
REN. The  last  edition.  In  one  volume,  octavo, 
extra  cloth,  54S  pages.  $2  80 
DEWEES'S  TREATISE  ON  THE  DISEASES 
OF  FEMALES.  Tenth  edition.  In  one  volume, 
octavo   extra  cloth,  532  pages,  with  plates.  $3  CO 


12 


BLANCHARB   &    LEA'S    MEDICAL 


DUNGLISON    (ROBLEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

NEW  AND  ENLARGED  EDITION. 

MEDICAL  LEXICON;   a  Dictionary  of  Medical  Science,  containing  a  concise 

Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Patholos-y,  Hv°-iene 
Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  Jurisprudence,  Demi'itrv' 
fee.  Notices  of  Climate  and  of  Mineral  Waters;  Formulae  for  Officinal,  Empirical,  and  Dietetic 
Preparations,  &c.  With  French  and  other  Synonymes.  Revised  and  very  greatlv  enlaro-ed 
In  one  very  large  and  handsome  octavo  volume,  of  992  double-columned  pages,  in  small  tvo- 
strongly  boimd  in  leather,  vi'itli  raised  bands.    Price  $4  00.  ro     >  jt^, 

Es^pecial  care  has  been  devoted  in  the  preparation  of  this  edition  to  render  it  in  every  resnect 
worthy  a  continuance  of  the  very  remarkable  favor  vi'hich  it  has  hitherto  enjoyed  The  rapid 
sale  of  Fifteen  large  editions,  and  the  constantly  increasing  demand,  show  that  it  is  reo-ardedbv 
the  profession  as  the  standard  authority.  Stimulated  by  this  fact,  the  author  has  endeavored  in  the 
present  revision  to  mtroduce  whatever  might  be  necessary  "  to  make  it  a  satisfactory  and  desira- 
ble—if  not  indispensable— lexicon,  in  which  the  student  may  search  without  disappointment  for 
every  term  that  has  been  legitimated  in  the  nomenclature  of  the  science."  To  accomplish  this 
large  additions  have  been  found  requisite,  and  the  extent  of  the  author's  labors  may  be  estimated 
from  the  fact  that  about  Six  Thousand  subjects  and  terms  have  been  introduced  throughout  ren- 
dering the  whole  number  of  definitions  about  Sixty  Thousand,  to  accommodate  which  the  num- 
ber of  pages  has  been  increased  by  nearly  a  hundred,  notwithstanding  an  enlargement  in  the  size 
of  the  pag:e.  The  medical  press,  both  in  this  country  and  in  England,  has  pronounced  the  work  in- 
dispensable to  all  medical  students  and  practitioners,  and  the  present  improved  edition  will  not  lose 
that  enviable  reputation. 

The  publishers  have  endeavored  to  render  the  mechanical  execution  worthy  of  a  volume  of  such 
universal  use  in  daily  reference.  The  greatest  care  has  been  exercised  to  obtain  the  tvpoaranhical 
accuracy  so  necessary  in  a  work  of  the  kind.  By  the  small  but  exceedingly  clear  type  emploved 
an  immense  amount  of  matter  is  condensed  in  its  thousand  ample  pages,  while  the  bindin"-  will  be 
found  strong  and  durable.  With  all  these  improvements  and  enlargements,  the  price  has  been  kest 
at  the  former  very  moderate  rate,  placuig  it  within  the  reach  of  all.  ^ 


This  work,  the  appearance  of  the  fifteenth  edition 
of  which,  it  has  become  uur  duty  and  pleasure  to 
announce,  is  perhaps  the  most  stupendous  monument 
of  labor  and  erudition  in  medical  literature.  One 
would  hardly  suppose  after  constant  use  of  the  pre- 
cedinsr  editions,  where  we  have  never  failed  to  find 
a  sufficiently  full  explanation  of  ever)  medical  term, 
that  in  this  edition  ^' about  six  thousand  subjects 
and  terms  have  been  added,'^  with  a  careful  revision 
and  correction  of  the  entire  work.  It  is  only  neces- 
sary to  announce  the  advent  of  this  edition  to  make 
it  occupy  the  place  of  the  preceding  one  on  the  table 
of  every  medical  man,  as  it  is  without  doubt  the  best 
and  most  comprehensive  work  of  the  kind  which  has 
ever  appeared.— J5 w#aio  Med.Journ.,  Jan.  1858. 

The  work  is  a  monument  of  patient  research, 
skilful  judgment,  and  vast  physical  labor,  that  will 
perpetuate  the  name  of  the  author  more  effectually 
than  any  possible  device  of  stone  or  metal.  Dr. 
Dunglison  deserves  the  thanlfs  not  only  of  the  Ame- 
rican profession,  but  of  the  whole  medical  world. 

North  Am.  Medico-Chir.  Review,  Jan.  1858. 

A  Medical  Dictionary  better  adapted  for  the  wants 
of  the  profession  than  any  other  with  which  we  are 
acquainted,  and  of  a  character  which  places  it  far 
above  comparison  and  competition. — Am.  Journ. 
Med.  Sciences,  Jan.  1858. 

We  need  only  say,  that  the  addition  of  6,000  new 
terms,  with  their  accompanying  definitions,  may  be 
said  to  constitute  a  new  work, "by  itself.  We  have 
examined  the  Dictionary  attentively,  and  are  most 
happy  to  pronounce  it  unrivalled  of  its  kind.  The 
erudition  displayed,  and  the  extraordinary  industry 
which  must  have  been  demanded,  in  its  preparation 
and  perfection,  redound  to  the  lasting  credit  of  its 
author,  and  have  furnished  us  with  a  volume  indis- 
pensable at  the  present  day,  to  all  wlio  would  find 
themselves  au  7iiveau  with  the  highest  standards  of 
medical  information.— Boszo^t  Medical  and  Surgical 
Journal,  Dec.  31,  1857. 

Good  lexicons  and  encyclopedic  works  generally, 
are  the  most  labor-saving  contrivances  which  lite- 
rary men  enjoy;  and  the  labor  which  is  required  to 
produce  them  in  the  perfect  manner  of  this  example 
18  something  appalling  to  contemplate.    The  author 


tells  us  in  his  preface  that  he  has  added  about  six 
thousand  terms  and  subjects  to  this  edition,  which, 
before,  was  considered  universally  as  the  best  work 
of  the  kind  in  any  language.— Silliman's  Journal. 
March,  1858.  ' 

He  has  razed  his  gigantic  structure  to  the  founda- 
tions, and  remodelled  and  reconstructed  the  entire 
pile.  No  less  than  six  thousand  additional  subjects 
and  terms  are  illustraled  and  analyzed  in  this  new 
edition,  swelling  the  grand  aggregate  to  beyond 
sixty  thousand  !  Thus  is  placed  before  the  profes- 
sion a  complete  and  thorough  exponent  of  medical 
terminology,  without  rival  or  possibility  of  rivalry. 
— Nashville  Journ.  of  Med.  and  Surg.,  Jan.  1858. 

It  is  univers.ally  acknowledged,  we  believe,  that 
this  work  is  incomparably  the  best  and  most  com- 
plete Medical  Lexicon  in  the  English  language 
The  amount  of  labor  which  the  distinguished  author 
has  bestowed  upon  it  is  truly  wonderful,  and  the 
learning  and  research  displayed  in  its  preparation 
are  equally  remarkable.  Comment  and  commenda- 
tion are  unnecessary,  as  no  one  at  the  present  day 
thinks  of  purchasing  any  other  P.Iedical  Dictionary 
than  this.— S«.  Louis  Med.  and  Surg.  Journ.,  Jan. 
1858. 

It  is  the  foundation  stone  of  a  good  medical  libra- 
ry, and  should  always  be  included  in  the  first  list  of 
books  purchased  by  the  medical  student.— ^w.  Med, 
Monthly,  Jan.  1858. 

A  very  perfect  work  of  the  kind,  undoubtedly  the 
most  perfect  in  the  English  language.— Jlfed.  and 
Surg.  Reporter,  Jan.  1858. 

It  is  now  emphatically  the  Medical  Dictionary  of 
the  English  language,  and  for  it  there  is  no  substi- 
tute.—JV.  H.  Med.  Journ.,  Jan.  1858. 

It  is  scarcely  necessary  to  remark  that  any  medi- 
cal library  wanting  a  copy  of  Dunfflison's  Lexicon 
must  be  imperfect. — Cin.  Lancet,  Jan.  1858. 

We  have  ever  considered  it  thebestauthority  pub- 
lished, and  the  present  edition  we  may  safely  say  has 
no  equal  in  the  world. — Peninsular  Med.  Journal, 
Jan.  1858.  ' 

The  most  complete  authority  on  the  subject  to  be 
found  in  anylanguage.— Ta.  Med.  Journal,  Feb.  '58. 


BY  THE  SAME   AUTHOR. 

THE  PRACTICE  OP  MEDICINE.     A  Treatise  on  Special  Pathology  and  The- 

rapeutics.    Third  Edition.    In  two  large  octavo  volumes,  leather,  of  1,500  pages.    §6  25. 


AND    SCIENTIFIC    PUBLICATIONS. 


13 


DUNGLISON    (ROBLEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  tlie  Jefferson  Medical  College,  Philadelphia. 

lUMAN  PHYSIOLOGrY.  Eighth  edition.  Thoroughly  revised  and  exten- 
sively modified  and  enlarged,  with  five  hundred  and  thirty-two  illustrations.  In  two  large  and 
handsomely  printed  octavo  volumes,  leather,  of  about  1500  pages.     $7  00. 

In  revising  this  work  for  its  eighth  appearance,  the  author  has  spared  no  labor  to  render  it  worthy 
I  continuance  of  the  very  great  favor  which  has  been  extended  to  it  by  the  profession.  The  whole 
jontents  have  been  rearranged,  and  to  a  great  extent  remodelled  ;  the  investigations  which  of  late 
^ears  have  been  so  numerous  and  so  important,  have  been  carefully  examined  and  incorporated, 
ind  the  work  in  every  respect  has  been  brought  up  to  a  level  with  the  present  slate  of  the  subject. 
The  object  of  the  author  has  been  to  render  it  a  concise  but  comprehensive  treatise,  containing  the 
whole  body  of  physiological  science,  to  which  the  student  and  man  of  science  can  at  all  times  refer 
with  the  certainty  of  finding  whatever  they  are  in  search  of,  fully  presented  in  all  its  aspects;  and 
on  no  former  edition  has  the  author  bestowed  more  labor  to  secure  this  result. 

We  believe  that  it  can  truly  be  said,  no  more  com-  i  The  best  work  of  the  kind  in  the  English  lau- 
plete  repertory  of  facts  upon  the   subject  treated,  I  guage. — Silliman's  Journal. 

can  anywhere  be  found.  The  author  lias,  moreover,  j  -j-j^g  present  edition  the  author  has  made  a  perfect 
that  enviable  tact  at  description  and  that  facility  |  mirror  of  the  science  as  it  is  at  the  present  hour. 
and  ease  of  expression  which  render  him  peculiarly  j  ^g  ^  work  upon  physiology  proper,  the  science  of 
"''  ■^'"     the  functions  performed  by  the  body,  the  student  will 

find  it  all  he  wislies. — Nashville  Journ.  of  Med. 
That  he  has  succeeded,  most  admirably  succeeded 
in  his  purpose,  is  apparent  from  the  appearance  of 
an  eighth  edition.  It  is  now  the  great  encyclopaedia 
on  the  subject,  and  worthy  of  a  place  in  every  phy- 
sician's library. — Western  Lancet. 


ar-reptable  to  the  casual,  or  the  studious  reader. 
This  faculty,  so  requisite  in  setting  forth  many 
graver  and  less  attractive  subjects,  lends  additional 
charms  to  one  always  fascinating. — Boston  Med. 
wild  Surg.  Journal. 

The  most  complete  and  satisfactory  system  of 
Physiology  in  the  English  language.— ^»raer.  Med. 
Journal .  ' 

BY  THE  SAME  AUTHOR.     {A  new  edition.') 

GENERAL    THERAPEUTICS    AND    MATERIA  MEDIC  A;   adapted  for  a 

Medical  Text-book.  With  Indexes  of  Remedies  and  of  Diseases  and  their  Remedies.  Sixth 
Edition,  revised  and  improved.  With  one  hundred  and  ninety-three  illustrations.  In  two  large 
and  handsomely  printed  octavo  vols.,  leather,  of  about  1100  pages.    $6  00. 


The  work  will,  we  have  little  doubt,  be  bought 
and  read  by  the  majority  of  medical  students;  its 
size,  arrangement,  and  reliability  recommend  it  to 
all ;  no  one,  we  venture  to  predict,  will  study  it 
without  profit,  and  there  are  few  to  whom  it  will 
not  be  in  some  measure  useful  as  a  work  of  refer- 
ence. The  young  practitioner,  more  especially,  will 
find  the  copious  indexes  appended  to  this  ediiion  of 
great  assistance  in  the  selection  and  preparation  of 
suitable  iox'ovvX-s,.— Charleston  Med.  Journ.  and  Re- 
view, Jan.  1858. 


In  announcing  a  new  edition  of  Dr.  Dunglison's 
General  Therapraties  and  Materia  Medica,  we  have 
no  words  of  commendation  to  bestow  upon  a  work 
whose  merits  have  been  heretofore  so  often  and  so 
justly  extolled.  It  must  not  be  supposed,  however, 
that  the  present  is  a  mere  reprint  of  the  previous 
edition;  the  character  of  the  author  for  laborious 
research,  judicious  analysis,  and  clearness  of  ex- 
pression, is  fullv  sustained  by  the  numerous  addi- 
tions he  has  made  to  the  work,  and  the  careful  re- 
vision to  which  he  has  subjected  the  whole.— iV.  A. 
Medico-Chir.  Review,  Ja.n.  1858. 

BY  THE  SAME  AUTHOR.     {A  new  Edition.) 

NEW  REMEDIES,  WITH  FORMULA  FOR  THEIR  PREPARATION  AND 

ADMINISTRATION.     Seventh  edition,  with  extensive  Additions.    In  one  very  large  octavo 

volume,  leather,  of  770  pages.    $3  75. 

Another  edition  of  the  "  New  Remedies"  having  been  called  for,  the  author  has  endeavored  to 
add  evervlhing  of  moment  that  has  appeared  >^mee  the  publication  of  the  la*t  edition. 

Thranicle^trea^d  of  in  the  former  editions  will  be  found  to  have  undergone  considerable  ex- 
nan^on  in  thTs  in  order  that  the  author  might  be  enabled  to  introduce,  as  iar  as  practicable  the 
P  fX^!f  thTs,  b^eauen  exuerience  of  others,  as  well  as  of  his  own  observation  and  reflection , 
^nT  omifthfwoKirn^oe  deservil  of  the  extended  circulation  with  which  the  preceding 
edftions  have  Ler?avoreJ  "y  he  professitm.  By  an  enlargement  of  the  page,  the  numerous  addi- 
Sns  have  been  Incorporated  without  greatly  increasing  the  bulk  of  the  voiume.-Pr.>«.. 


One  of  the  most  useful  of  the  author's  works.— 
Southern  Medical  and  Surgical  Journal. 

This  elaborate  and  useful  volume  should  be 
found  in  every  medical  library,  for  as  a  book  of  re- 
ference, for  physicians,  it  is  unsurpassed  by  any 
other  work  in  existence,  and  the  double  index  tor 
diseases  and  for  remedies,  will  be  tound  greatly  to 
enhance  its  vaXw.—New  York  Med.  Gazette. 


The  great  learning  of  the  author,  and  his  remark- 
able industry  in  pushing  his  researches  into  every 
source  whence  information  is  derivable,have  enabled 
him  to  throw  together  an  extensive  mass  of  facts 
and  statements,  accompanied  by  full  reference  to 
authorities;  which  last  feature  renders  the  work 
practically  valuable  to  investigators  who  desire  te 
examine  the  original  papers.-TAe  American  Journal 
of  Pharmacy. 


ELLIS  (BENJAMIN),  M.D. 
THF   MEDICAL  FORMULARY:   being  a  Collection  of  Prescriptions,  derived 

"^^om  t^w^ilS^L  pra^^^^  of  the  m|t  ---  Physi.a.s  of  A^^^^ 

Together  with  the  usual  Dietetic  Preparations  ^^^d  Ai  idotes  tor  r^    ons  ^j^^ 


14 


BLANCHAK.D    &   LEA'S   MEDICAL 


ERICHSEN   (JOHN), 
„„„  "Pro^^ssoT  Of  Surgery  in  University  College,  London   &e 

THE  SCIENCE  AND  ART  OF  SURGERY;  beng  a  Treatise  on  SnEGiCAi 

In  one  large  and  handsome  octavo  vZme    of  oTethonsiTJ'™,'^'^'^  ^"^^^^^         on  wood. 
raised  bands.     $4  50.     (Just  Issued.)  '  thousand  closely  printed  pages,  leather, 

attained  as  a  standard  aiathorily.  Eve  ypor"irhas  been  oarefnlPv''""  T^'°^  ''  ^^'  '°  '''^P''"y 
have  been  made,  and  the  most  watchful  care  ha"  been  Pver.?lf  f  ^  T"^"^'  """serous  additions 
of  the  most  advanced  condition  of  sur-  caTscien^P      Tn  ,h  ''  '°  ''u"'^"  V  ^  complete  exponent 

about  a  hundred  pa^es,  wh  e  Ve  .  "ne    of  en'ravin  A.J^^  '^^  T^^  ^^^  '^^^^'^  ^"^^'•S^ed  by 

rendering  it  one  of  fhe'most  thorouSy  iUustrf le  J  vf h,?,ll^  increased  by  more  than  a  hundred, 
the  author  having  rendered  imnecelsary  S  of  h^no  es  of  t^^^^^^^^^^^  ^>  ^^^'"'°"«  °^ 

has  been  added  in  this  country;  some  few  notes  «nHnn?.^  ?  n  '''"'  ^^encan  editor,  but  little 
introduced  to  elucidate  American  m^desoT  pmctice  °"'^^^'°""'  illustrations  have,  however,  been 
>iV!;;':.2'l';Ji;''?!".t^^?",?.'^^'^«-'^«'<ily  the  best  I  step  of  the  operation,  and  not  desertin.  him  until  the 


book  of  the  kind  in  the  English  language  Stran'^'^e 
that  just  such  books  are  not oflener  produced  by  pub- 
lie  leacheTs  of  sur-ery  in  this  country  and  Great 
BritauL  Indeed  It  is  a  matter  of  great  astonishment, 
but  no  less  true  than  astonishing,  that  of  the  many 
works  on  surgery  republished  in  this  country  within 
the  las  fineen  or  twenty  years  as  text-books  for 
medical  students,  this  IS  the  only  one  that  even  ap- 
proximaiesto  ihe  rulfilmem  of  the  peculiar  wants  of 
youngmen  juslenleringuponthe  study  of  thisbranch 
ot  the  proiession.—  Western  Jour,  of  Med.  and  Surgery. 

lis  value  is  greatly  enhanced  by  a  very  conious 
well-arrangedfndex.  We  regard  This  HontofTe 
most  valuable  contributions  to  modern  suro-ery  To 
one  entering  his  novitiate  of  practice,  we^regkrd  il 


final  issue  of  the  case  is  decided.— Sez'^oscoye. 

Embracing,  as  will  be  perceived,  the  whole  surgi- 
nfit^Tn'"'  V"^  each  division  of  itself  almost  com- 
plete  and  perfect,  each  chapterfull  and  explicit  each 
subjectfaithfully  exhibited  we  can  only  exprek  o«' 
estimate  of  it  in  the  aggregate.  We  consider  it  an 
excellent  contribution  to  surgery,  as  probably  the 
best  single  volume  now  extai^t  on  the  subjectf  and 
with  great  pleasure  we  add  it  to  our  text-books - 
Nashville  Journal  of  Medicine  and  Surgery. 

Prof.  Erichsenjs  work,  for  its  size,  has  not  beeri 

surpassed;  his  nine  hundred  and  eight  pa-es    nro- 

fusely  Illustrated,  are  rich  in  physiolSgickl,"paiholo- 

gical,  and  operative  suggestions,  doctrines,  detail 

the  mos,  serviceable  g;,iTew"hichl,;7anc7n/uT'U' I  ^^'r'^i  P/°'^«^^«^  i  .^"d  will^prove  a  reliable  ^esou^ce 

win  lind  a  rulnessof  detailleadin^hYm^SgreviS  I  ^'^^^'^^'^ ^^1^^^^]^^:^^ '»  *^^ 

FLINT  (AUSTIN),  M.   D. 

Professor  of  the  Theory  and  Practice  of  Medicine  in  the  University  of  Loui.vfJl.   ;. 

PHYSICAL  EXPLORATION  AND  DIAGNOSIS  OP  dYwaqI^q  ?T;T.i:.nm 

ING  THE  RESPIRATORY  ORGANS  In  one  llVe  and  V.„/^^^  AFFECT^ 
cloth,  636  pages.     $3  00.  ^"  ''"«  '^"^^e  'ind  handsome  octavo  volume,  extra 

We  regard  it,  in  point  both  of  arrangement  and  of 

the  marked  ability  of  its  treatment  of  the  subjects 

as  destined  to  take  the  iirst  rank  in  works  of  this 

class.    So  far  as  our  information  extends,  it  has  at 

present  no  equal.     To  the  practitioner,  as  well  as 

the  student,  it  will  be  invaluable  in  clearino-  up  the 

diagnosis  of  doubtful  cases,  and  in  sherlding  light 

upon  difficult  phenomena.— ^KjfaZo  Med.  Journal 


A  woi  k  of  original  observation  of  the  highest  merit 
We  recommend  the  treatise  to  every  one  who  wishes 
to  become  a  correct  auscultator.  Based  to  I  ve?v 
large  extent  upon  cases  numerically  examined  7t 
carries  the  evidence  of  careful  study  and  iCdmiia 
tion  upon  every  page.  It  does  credit  to  he'au^ho^- 
and  through  him,  to  the  profession  in  this  country' 
It  is,  what  we  cannot  call  every  book  upon  auscul  • 
tatum,  a  readable  book.-^^.  }our.  Med  Sciences. 
BY  THE  SAME  AUTHOR.     (Now  Ready  ) 

A  PRACTICAL  TREATISE  ON  THE  DIAGNOSIS    PATHOTOrv    AMn 

TREATMENT  OF  DISEASES  OF  THF  HFAT?T       t,,  '    ^^^^^^*^^^^   AND 

500  pages,  extra  cloth      $2  75  HEART.      In  one  neat  octavo  volume,  of  about 


We  do  no*  know  that  Dr.  Flint  has  written  any- 
thing which  is  not  first  rate  ;  but  this,  his  latest  con- 
tribution to  medical  literature,  in  our  opinion,  sur- 
passes all  the  others.  The  work  is  most  comprehen- 
sive m  Its  scope,  and  most  sound  in  the  views  it  enun- 
ciates. The  descriptions  are  clear  and  methodical  • 
the  statements  are  substantiated  by  facts,  ai'd  are 
made  with  such  simplicity  and  sincerity,  that  with- 
out them  they  would  carry  conviction.  The  style 
w^u"!^''*'''^  '^'''*"''  ''i''ect.  and  free  from  dryness 
With  Dr.  Walshe's  excellent  treatise  before  us,  we 
have  no  hesitation  in  saying  that  Dr.  Flint's  book  is 
the  best  work  on  the  heart  in  the  English  lan<-uao-e 
—Boston  Med.  and  Surg.  Journal,  Dec.  15,  1859? 

We  have  thus  endeavored  to  present  our  readers 
with  a  fair  analysis  uf  this  remarkable  work.  Pre- 
terring  to  employ  the  very  words  of  thedistinguished 
autnor,  wherever  it  was  possible,  we  have  essayed 
to  condense  into  the  briefest  spaceageneral  viewof 
his  observations  and  suggestions,  and  to  direct  the 
attention  of  our  brethren  to  the  abounding  stores  of 
valuable  matter  here  collected  and  arranged  for  their 
use  and  instruction.  No  medical  library  will  here- 
alter  be  considered  complete  without  this  volume- 
and  we  trust  it  will  promptly  find,  its  way  into  the 

M    /      n7Vl.^'^''V'''"^  student  and  physician— 
N.  Am.  Med.  Chir.  Review,  Jan   1860. 

This  last  M^oik  of  Prof.  Flint  will  add  much  to 
his  previous  well-earned  celebrity,  as  a  wriier  of 
great  force  and  beauty,  and,  v/ith  his  previous  work 


",  ,  .-      --- - — ""/)""",  viiiiii  ilia  picviDus  w^orK,     readers  in 

places  him  at  the  head  of  American  writers  upoa    Feb.  1860. 


diseases  of  the  chest.  We  have  adopted  his  v/ork 
upon  the  heart  as  a  text-book,  believing  it  to  be 
more  valuable  for  that  purpose  than  any  work  of  the 
De"c   1859        ^''  appeared .-iVa./^^,^^^/iW,rf.  jZrn^ 

With  more  than  pleasure  do  eve  hail  the  advent  of 
his  work,  for  it  fills  a  wide  gap  on  the  list  cf  text- 
books for  our  schools,  and  is,  for  the  practitioner, 
t  i"?/  valuable  practical  work  of  its  kind.-iV  O 
Med.  News,  Nov.  IS59. 

In  regard  to  the  merits  of  the  work,  we  have  no 
hesitation  in  pronouncing  it  full,  accurate,  and  iu- 
dieious.  Considering  the  present  state  of  science 
such  a  work  was  much  needed.  It  should  be  in  the 
Apdf  f86o"'^'  practitioner. -CAicag-o  Med.  Journal, 

But  these  are  very  trivial  spots,  and  in  nowise 
prevent  us  from  declaring  our  most  hearty  approval 
of  the  author's  ability,  industry,  and  conscientious- 
F^b  Ts60  ""  '?''«««'-^J'  Journal  of  Med.  Sciences, 

He  has  labored  on  with  the  same  industry  and  care, 
and  his  place  among  the  first  authors  of  our  countrv 
is  becoming  fully  established.  To  this  end,  the  work 
Whose  title  is  given  above,  contributes  in  no  small 
aegree.  Our  spa3e  will  not  admit  of  sn  extended 
analysis,  and  we  will  close  this  brief  notice  by 
commending  it  without  reserve  to  every  class  of 
R  1  ^iftr'n  ^'^^  Pi'^fession.— PeramsM/ar  Med.  Journ., 


AND   SCIENTIFIC    PUBLICATIONS. 


]5 


FOWNES  (GEORGE),  PH.  D.,  &.C.  _ 

A  M\NUAL  OF  ELEMENTARY  CHEMISTRY;  Theoretical  and  Practical. 

From  the  seventh  revised  and  corrected  London  edition.    With  one  hundred  and  ninety-seven 

ilhisTratiou*      Edited  by  Robert  Bridges,  M.  D.     In  one  large  royal  12mo.  volume,  of  bOO 

pa<res      In  leather,  f  1  65 ;  extra  cloth,  $1  50.     {Jmt  Issued.) 

The  death  of  the  author  having  placed  the  editorial  care  of  this  work  in  the  practised  hands  of 
Drt  Bence  Jones  and  A.  W.  Hoffman,  everything  has  been  done  in  its  revision  whidi  experience 
Suid  s  -e"!"  to  keep  it  on  a  level  with  the  rapid  advance  of  chemical  science.  The  additions 
reautileTo  this  purpose  have  Heces>itated  an  enlargement  of  the  page,  notwithstanding  which  the 
work  has  been  increased  bv  about  fifty  pages.  At  the  same  time  every  care  has  been  u~ed  to 
^[nta^^^trd  "tmct've  character  as  a  ci.ndensed  manual  for  the  student,  divested  of  al  unnecessarv 
So  mere^heoretical  speculation.  The  additions  have,  of  course,  been  mamly  m  the  depar  - 
ment  ot'oi-anic  Chemistry,  which  has  made  such  rapid  progress  withm  the  last  fevv  years,  but 
yet  eq°  al  anent?on  has  been  bestowed  on  the  other  branches  of  the  subject-Chemical  Physics  and 
Tnoro-a  dc  Chem.stry-to  present  all  investigations  and  discoveries  of  importance  and  to  keep  up 
Jhe  renumUon  of  the  volume  as  a  complete  manual  of  the  whole  science  admirably  adapted  for  the 
earner  Bv  the  use  of  a  small  but  exceedingly  clear  type  the  matter  of  a  large  octavo  is  compressed 
Sfn  ihe  convenien°and  portable  limits  of  a  moderate  sized  duodecimo,  and  at  the  very  low  price 
affixed,  it  "is  offered  as  one  of  the  cheapest  volumes  before  the  profession. 

Dr  Fownes' excellent  work  has  been  universally        '^'^-  ...-.t  -f  r.r    Fn 
recoo^nized  everywhere  in  his  own  and  tins  country, 
as  the  best  elementary  treatise  on  cliemiscry  in  the 


The  work  of  Dr.  Fownes  has  long  been  before 
the  public,  and  its  merits  have  been  fully  appreci- 
ated as  the  best  text-book  on  chemistry  now  in 
existence.    We  do  not,  of  course,  place  it  in  a  ranK 


Wi^Sm^^!^!^PlS^t=^^^ 


both  lite'-aryand  ^cie-aii^c— Charleston  Med  Journ 
and  Review,  Sept.  1S59. 

A  standard  manual,  which  has  long  enjoyed  the 
reputation  of  embodying  much  knowledge  in  a  small 
space  The  author  hasachieved  the  difficult  task  oi 
condensation  with  masterly  tact.  His  book  is  con- 
cise without  being  dry,  and  brisf  without  being  too 
dogmatical  or  general.- Virgzjua  Med.  and  Surgical 
Journal. 


Gregory,  or  Gmelin,  but  we  say  that,  as  a  work 
for  students,  it  is  preferable  to  any  of  them.— -Lom- 
don  Journal  of  Medicine. 

A  work  well  adapted  to  the  wants  of  the  student 
It  is  an  excellent  exposition  of  the  chief  doctrines 
and  facts  of  modern  chemistry.  Thesizeof  the  work, 
and  still  more  the  condensed  yet  perspicuous  style 
in  which  it  is  written,  absolve  it/'-"^^ '^f  «li"S" 
irprv  nrooerlv  uro-ed  against  most  manuals  termed 
lollC-Edinburgk  Journal  of  Medical  Science. 


FISKE  FUND  PRIZE  ESSAYS  -THE  EF- 
FECTS OF  CLIMATE  ON  TUBERCULOUS 
DISEASE  BvEdwtn  Leb,M.R.C.S  .London, 
and  THE  IXFLUENCE  oF  PREGNANCY  ON 
THE  DEVELOPMENT  OF  TUBERCLES     By 


Edwam  Wakeen,  M.  D-,  of  Edenton  N  C  To- 
gether in  one  neat  8vo  volume,  extra  cloth.  $1  uu. 
FRICK  Ox\  RENAL  AFFECTIONS;  tUeirDiag- 
nosU  and  Pathology.  With  illustrations.  One 
volume,  royal  r2ino.,  extra  cloth.     /5  cents 


FERGUSSON  (WI  LLI  AM),  F.  R..  S., 

Professor  of  Surgery  in  King's  College,  London,  &c. 

A   SYSTEM  OF  PRACTICAL  SUEGERY.     Fourth  Amenean   from  the  bird 
\S!^L«don  eaaion.    I.  ,«e  l.r.e  and  «,„,.y  pm-ed  oCavo  volume,  o,  .bou.  700 
pages,  wkh  393  handsome  lUustratioas,  leather.     $3  00- 

G RA H A IVT (THOMAS)^  F.  R.  S.  .,       *      T  o 

TTTF  ETEMENTS   OF   INORGANIC   CHEMISTRY,  includmg  the  Applica- 

hat  separate,  cloth  backs  and  paper  sides.    Price  $2  50  ^^^^^,^ 

Frorn  Prof.  E.  N.  Horsford,  Harvard  College.      ;  ^^-^^^^^^l -/*na»*>^^  1^53. 

faS't'o  !^rrJrtVe1ie:iircro'f1trp°:n\Td  I     ^.„,  ,rof  Wolcou  ai„.s,  N.  Y.  Tree  Academy^ 
S'clSmesrand  completeness  of  its  discassions,        ^,^  ^^..^  ^^  -V'"""''%T  u'?, 'eUrtSitive 

f^RIFFITH  (ROBERT   E.),   M.  D.,  &c. 

.    TmTTTrc^i?QAT   ^ORAIULARY,  containing  the  methods  ot  Preparing  and  Ad- 

A  UNIVERSAL  ■P^^-^^*-'-Vr'j'Th«whnle  adapted  to  Physicians  and  Pharmaceu- 
mmistering  Officinal  and  other  Med ic.nes  ^^^^-^^^^^.TJaLuI  by  Robert  P.  Thom.s, 
tists.  Second  Edition,  thoroughly  ."^J^f  ^l^Tadebhia  College  of  Pharmacy.  In  one  large  and 
M,  D.,  Professor  of  Materia  Medicain  the  Phi^^^^^^^^^^  ^3  ^^Y  ^^  .^  ^.^^^^  ^3  25. 

handsome  octavo  volume,  extra  clotH,      o   j.  „     ,  ^.^  ^^^^^^^^  ^^^  fifty- one  pages, 

.mbracin-  all  on  the  subject  of  preparing  a"d  admi- 
'"t'enng  medicines  that  can  be  desire^  by  the  physl- 


It  was  a  work  requiring  much  Pf  f /erance   and 

SSl!ln^^\fitSV^^SS"- 
Sas^J^^=V5fS£e^^i 

S^sa!!^Ss=.^i"---^;-— 
Wearehappy  to  announce  anew  and^^ 


cianand  pharmaceutist.- TVestfim  La?icet. 

The  amount  of  useful,  eyery-day  m=ilter.for  a  prac- 
ticing physician,  is  really  immense.-.Bosion  Med. 
and%irg.  Journal. 

This  edition  has  been_  greatly  improved  by  the  re- 


We  are  happy  to  -nounce  a  n        a       -prov^^^  ,  i 

edition  of  this,  one  °f  the  most  valuable  an  „     vision^.         .^1^      ^^^^  ^^  ^,^  =°,'"''T,ZmU 

rielLsouthern  Med.  and  Surg.  Journal.  Xicia     and  hereTs  none  .ve  can  more  cordially 


lb' 


BLANCHARD   &    LEA'S   MEDICAL 


,,  GF^OSS  (SAMUEL  DJ,   M.  D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  &c. 
Just  Issued. 
A  SYSTEM  OF  SURGERY:  Pathological,  Diagnostic  Thprineutic  -^n^  O 

tive.  IlluMrated  by  Nine  Hundred  AND  THmT^ENGPAviNGs  Tn  f!P  i  '  ??  ^P^""^- 
printed  octavo  volumes,  of  nearly  twentv-foiir  hnndrp^\f.tir.  ,  ,  ^Y°  ''"'»^  ""'"^  beautifully 
raised  bands.     Price  §12.  ^  ^  imndred  pages  ;  strongly  bound  in  leather,  with 

From  the  Author's  Preface 

faithful  and  availab'le  guide  in  his  dailv  routit  of  dut^  '  l'  ha  been  too  m^^Jh  ,?'  P-c^itioner  as  a 
ern  writers  on  this  department  of  the  healing  art  to  omit  certain  fo™V?«^o^M'''  ''"'\°'"  °^  '"•"^- 
olhers  at  undue  length,  evidently  assurain-  Uiat  their  reader  r^^^M^  I,  i  ^^'^7'  ''"'^  '^  ^P^^k  ol 
from  other  sources,^  that  what  has  brn^E.^Ldl' of  n"^^^^^  '"^''^  ""^  ^deficiencies 

has  been  to  embrace  the  whole  domain  of  surgery  and  to  alloUo  e  e!^^!  ^wT-'^  T'""'  ^^  ^'"^ 
to  notice  in  the  great  family  of  external  diseasef  and  aocide.n"  How  rJ  Tu^^f-  "'  ['^S-ilimate  claim 
phshed,  it  is  not  for  me  to  determine  It  mav  "afe^v  t  ^ffl.,.  i^T  '  *'"'*  ""^J^^^  ''^^  '^'^e"  accom- 
properiy  appertaining  to  surgeryrthat  wi  1  no7be  fou nd^n  hf ,'"'''  ^T^^^*"'  '^^^t  there  is  no  topic, 
in  these  volumes.     If  a  larger  s^nSthln  is  cu<tS"arv  L^  W  ^''T"^''  °^  '^^^  ^^»«"' 

inflammation  and  its  results,  or  the  great  prindnrs  of  ^nr!^f  ^.'"'^^u''  ^°  '^'"^  consideration  of 
grounded  upon  long  and  clJse  observS  '^hat  there  are  nf^f?  f  ^"?"f  °^  ^^'^  conviction, 
general  practitioner?  Special  attention  Edso  been  bestowed  unSn  fh'.  H°  ^'"'^  ""'^^^^to^d  by  the 
and  an  elaborate  chapter  has  been  introduced  on  ge'reraTiiao-^osif''         '^^^^^"'«'"^t^«»  of  diseases; 

ihat  these  intentions  have  been  carried  out  in  the  fiillp«f  ^,^,1  ^,^U„i  i.      . 
shown  by  the  great  extent  of  the  worrand  the    en4h  of  t^mt  ^?    ^      ^°^^'!  '"u^""^'"  '^  ^efficiently 
concentrating  on  the  task  his  studies  a^id  hi    IxSceSedb?tL^  ''''\°?'  u^"*  ^^'"^ 

years  of  lecturing  on  surgical  topics  have  given  h'Jo'nhe^wanfs SlE:  prXSof  "'"'  ^""^^^ 

Ul  Dr.  dross's  treatise  on  Surgery  we  can  say  ' 
no  more  than  that  it  is  the  most  elaborate  and  com- 
plete work  on  this  branch  of  the  healing  art  which 
has  ever  been  published  in  any  country.  A  sys- 
tematic work,  it  admits  of  no  analytical  review 
but,  did  our  space  permit,  we  should  gladly  give 
some  extracts  from  it,  to  enable  our  readers  to  iudee 
of  the  classical  style  of  the  author,  and  the  exhaust- 
ing way  in  which  each  subject  is  treated.-jDwiZm 
quarterly  Journal  of  Med.  Science,  Nov.  1859. 

The  work  is  so  superior  to  its   predecessors  in 
matter  and  extent,  as  well  as  in  illustrations  and 


,  ,;:•.' —  "^.i  CO  111  iiiuBLiatiuDs  ana 

style  of  publication,  that  we  can  honestly  recom- 
mend It  as  the  best  work  of  the  kind  to  be  taken 
Ja^^lSGO        '"'^"^  practitioner.— 4w.  Med.  Journ., 

The  treatise  of  Prof.  Gross  is  not,  therefore,  a 
mere  text-book  for  undergraduates,  but  a  systema- 
tic record  of  more  than  thirty  years'  experience 
reading,  and  reflection  by  a  man  of  observation 
sound  judgment,  and  lare  practical  tact,  and  as  such 
deserves  to  take  rank  with  the  renowned  produc- 
tions of  a  similar  character,  by  Vidal  and  Boyer  of 
France,  or  those  of  Chelius,  Blasius,  and  Lansen- 
beck,  of  Germany.  Hence,  we  do  not  hesitate  to 
express  the  opinion  that  it  will  speedily  take  the 
same  elevnl.ed  position  in  regard  to  surgery  that  has 
been  given  by  common  consent  to  the  masterly  work 
of  Pereira  m  IVIateria  Mediija,  or  to  Todd  and  Bow- 
Ja^  \"ggP'^>'^i°i"&y— ■^-  O .  Med.  amd  Sv^g.  Journal, 


At  present,  however,  our  object  is  not  to  review 

s^mnr'.n  "'"'  ^"^  ^"'P'^^^  ""'""  hereatterrbTt 
simply  to  announce  Us  appearance,  that  in  the 
meantime  our  readers  may  procure  a,  d  examine  i? 
for  themselves.  But  even  this  much  we  cannot  do 
without  expressing  the  opinion  that,  in  putting  forth 
these  two  volumes.  Dr.  Gross  has 'reared  fo?  him- 
self a  lasting  monument  to  his  skill  as  a  surgeon, 
and  to  his  industry  and  learning  as  an  author  -s"' 
Loms  Med.  and  Surg.  Journal,l^ov   1S59 


AVith  pleasure  we  record  the  completion  of  this 
long-anticipsted  work.  The  reputation  ^vhich  the 
author  has  for  many  years  sustained,  both  as  a  sur- 
geon  and  as  a  writer,  had  prepared  us  to  expec?  a 
treatise  of  great  excellence  and  originality ,  but  we 
whil'' T  r"'  '"^  "?  '"'^^"^  P^^^P^'ed  tor  the  woTk 
which  IS  before  us-the  most  complete  tre.atiseupon 
surgery  ever  published,  either  in  this  or  any  otCr 
country,  and  we  might,  perhaps,  safely  say  the 
most  original.  There  is  no  subject  belongi^J'pro! 
perly  to  surgery  which  has  not  received  from  the 
authoi  a  due  share  of  attention.  Dr.  Gro^s  has  sun! 
Plied  a  want  m  surgical  literature  which  has  long 
been  fe  t  by  practitioners;  he  has  furnished  us  vA"h 
a  complete  practical  treatise  upon  surgery  in  all  its 
departments.  As  Americms,  we  are  proud  of  the 
H?«nkf,dT".''  ^r  ^"'•."'=°"«'  ^e  are  most  sincerely 

behalf.--JV.  Y  Monthly  Review  and  Buffalo  Med. 
Journal,  Oct.  1850.  jucm. 


BY  THE  SAME  AUTHOR. 

ELEMENTS  OF  PATHOLOGICAL  A ^ATorvTV     mi  •  ;i    j-.- 

Prtce  in  extra  cloV  H  75;  SLTrr^L^Jb^Sdt  S^'^ST  ^ 

r^:iZ::&tZ^^^^^i::^^£^  1^St^!r\^^^  ^r^  ^^  '-  ^ew  years  have 
nent  of  the  present  state  of  the  subiect      ThV  vL^^.  '  T  ^'^w  of  making  it  a  correct  expo- 

executed,  and  the  amount  of  alLration  which  ?t  la /nnr       "'T'''  "'  ^^'^^  '^'^  '^'^'  has  been 
"  with  the  many  changes  and   mpJreme,  Jnow  biZ^^^  ?^^'*'''  *^^  ^"^^o--  '^  ^ay  that 

a  new  treatise,'' while'tJie  eL nfof  thTamhor  hl^t.  h.      '  '^^  T'^  '"^^  ^^  regarded  almost  as 
execution  of  the  volume,  renderingit  te^^he^  htloS^t  ^^^^Son^If^^L^^Z'^'^ 

proposed  object.    His  book  is  most  admfn  b ly  ca  of  >,T,T'  '"  "^''"'^  ^J"'  ^'"^^  ^''^  executed  his^task 

culated  to  fill  up  ablank  which  has  long  been  fdt  to  state  of  Z^ft  ''TP'^'^'Jf'^"  f'^"'^  "^  'h«  P^^^^nt 

exist  in  this  department  of  medical  literature  and  ul''^*' "'^  "'^ ''^'^'^*"'"e .of  Pathological  Anatomy,  and 

as  such  must  become  very  widely  c?rcua/edl^!^nJl^  ""^"^  pleasure  in  recommending  his  work  to 

all  classes  of  the   proflTon.  LoubhTilZteflv  Zlllf"''  ^1  ^^  "'""''^^  °"«  weirdeserTrng  of 

Journ.  of  Med.  Science,  Nov.  1857.             '■J^'^^terly  dih^ent  perusal  and  careful  study  .-Montreal  Med. 

.      _^  BY  THE  SAME  AUTHOR. 

sraEi^T^^"^!^  TREATISE  ON  FOREIGN  BODIES  IN  THE  AIR  PAS 

SAGES.    In  one  handsome  octavo  volume,  extra  cloth,  with  illustrations,    pp^ L     $5  75 


AND    SCIENTIFIC  PUBLICATIONS. 


17 


GROSS   (SAMUEL    D.),    M.  D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelpliia,  &e. 

A   PEACTICAL    TREATISE    ON    THE    DISEASES,    INJURIES,  AND 

MALFORMATIONS  OF  THE  URINARY  BLADDER,  THE  PROSTATE  GLAND,  AND 
THE  URETHR.A.  Second  Edition,  revised  and  much  enlarged,  with  one  hundred  and  eighty- 
four  illustrations.  In  one  large  and  very  handsome  octavo  volume,  of  over  nine  hundred  pages. 
In  leather,  raised  bands,  S5  25 ;  extra  cloth,  $4  75. 

Philos'^pliical  in  its  design,  methodical  in  its  ar-  '  agree  with  ns,  that  there  is  no  work  in  the  English 
ran<rement  ample  and  sound  in  its  practical  details,    language  which  can  malse  any  just  pretensions  to 
it  inay  in  truth  be  said  to  leave  scarcely  anything  to    be  its  equal.— iV.  Y.  Journal  of  Medicine. 
be  desired  on  so  important  a  subject. — Boston  Med.  j      Avolume  replete  with  truths  and  principles  of  the 
and  Surg  Journal .  atmost  value  in  the  investigation  of  these  diseases.   - 

Whoever  will  peruse  the  vast  amount  of  valuable  |  American  Medical  Journal . 
nraetical  information  it  contains,  will,  we  think,  I 


GRAY  (HENRY),   F.  R.  S., 

Lecturer  on  Anatomy  at  St.  George's  Hospital,  London,  &p.. 

ANATOMY,  DESCRIPTIVE  AND   SURGICAL.      The  Drawings  by  H.  Y. 

Catiter  iM.  D.,  late  Demonstrator  on  Anatomy  at  St.  George's  Hospital ;  the  Dissections  jointly 
by  the  Author  and  Dr.  Carter.  In  one  magnificent  imperial  octavo  volume,  of  nearly  800 
pao-es,  with  363  large  and  elaborate  engravings  on  wood.  Price  in  extra  cloth,  §b  2D,  leatner 
raised  bands,  S7  Oo!    (_Just  Issued.) 

The  author  has  endeavored  in  this  work  to  cover  a  more  extended  '"3"?%"^  ^"^je^ts  than  is 
customary  in  the  ordinary  text-books,  by  giving  not  only  the  details  necessary  for  the  =^tudent,  but 
KTe  anplication  of  thise  details  in  the  practice  of  medicine  and  surgery,  thus  rendering  it  both 
a  -a  de  \r  the  learner,  and  an  admirable  work  of  reference  for  the  active  practitioner.  The 
en^avhi^^  form  a  specid  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
Sal  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in  place  ol  figu  es 
of  refe  enoe  with  descriptions  at  the  foot.  They  thus  form  a  complete  and  spendid  serie.,  which 
wilTiSv  a™  the  student  i.i  obtsining  a  clear  idea  of  Anatomy,  and  will  also  serve  to  refresh 
S  memory  of  ho  ewio  may  find  in  thel^xigencies  ol  practice  the  necessity  of  recalling  the  details 
of  the  Q^^eltin-  room  ;  while  combining,  as  it  does,  a  complete  Atlas  of  Anatomy,  with  a  thorough 
f  ^  2  „n  Jv  T/rnatio  descrintive  and  applied  Anatomy,  the  work  will  be  found  of  essential  use 
;ralrphv.icirs"t  iecdvTsltid^^^^^^^^^  both  preceptor  and  pupil  of  much 

labor  in  laying  the  groundwork  of  a  thorough  medical  education. 

the  number  and   excellence   of  the  en   ravings  it  ,         ^  J"        ^  ^^^  muscles,  he  gives  a  concise 

contains.  Most  of  these  are  original  of  'uuc'i  ,  sta  em?nt  of  the  fractures  to  which  the  bones  of 
larger  than  ordinary  size,  and  admirab.)  efecuteo^  the  extremities  are  most  liable,  together  v.'ith  the 
The  various  partsare  also  lettered  alter  the  p^n  tl^^^'t^es  are  most  a  ^.^,  .^^_^^^^  ^^  ^^^.^^ 
adopted  in  HoWen's  Osteology.     It  would  be  Qiffi-     f/"°""t'inu    '  ^^hjected  by  muscular  action, 

cult  to  over-estimate  the  advantages  oAercd  by  this  J^^  '^^f  ™f„°^!,''J,'tex"es  is  remarkably  full  and  ac- 
mode  of  pic:or,al  il  ustration.     ^""^8    ligaments      J^^^  ^^ctn^^n  on  a  t  ^^^>^_^^^  ^^ 

muscles,  bloodvessels,  and  nerves  are  each  m  turn  e^^^^te  ^^s^^^^j  ,g„3^1  ^^^  directions  for  its  liga- 
figured,  and  marked  with  their  '^PPr^P^^t'; names  e/^-n  i7''7^  ^^^  ^f  ^'^g  description  of  each  arte- 
thusenab  iLg  the  student  to  ecmprehend.  at  a  glance      'wn,  but  a   rne  ^^^^_^        .  ^^^^  . 

what  would  otnerwise  often  be  ignored  or  at  anj  "^  ^''^j;^^''^'  occur  in  its  origin,  course,  and 
work  of  Mr    Gray  to  the  attention  of  the  meaical        ,,      Q^j,,.!g  ^ook,  in  excellency  of  arrangement 


profession,  feeling  certain  that  it  should  be  regarded            comoleteness  of  execution,  exceeds  any  work 
as  one  of  the  (n,.st  valuable  contributions  ever  made  •  ■  -  -  -'-  ^^--i-h  i.n. 


asuueu,  Lur.o..=,.  vc.,.^.... ^,     ^      .    „      on^anatomv'hrtVeVo  published  ^ 

to  educational  literature  -N.  Y.  Monthly  Review.  affording  a  complete  view  of  the  structure  of 


Dec.  1&59.  thehuraanbody,  with  especial  ''eference  to  practical 

In  this  view,  we  regard  the  work  of  Mr.  Gray  as  j  surgery.  Thus  the  volume  constitutes  a  perfect  book 

fo.V»i  !r  n,^Aie<l  to  the  wants  of  the  profession,    of  reference  for  the  practitioner,  demanding  a  place 

Ind  espe'ia  Iv'of  the    tud^^t   than  any  treatise  on  i  t  even  the  most  limite^  ^'''^^^>' °Vnr  ?h'e  s'tS?  ?o 

student   of  -general   or   relative   anatomy.  — iV.    Y.  l  terly  Journal  of  Med.  bctences,  i\ov.  i.^o^- 
Journal  of  Medicine,  Nov.  1659.  I      i„  our  judgment,  the  '^ode  of  illustration  adopted 

-This  is  by  all  comparison  the  most  excellent  work  -  j^  the  present  vol  urn.  f^"^  ,^"' P''«^'o"t\^^^rious 
or,   Atfatornv  extant      It  is  just  the  thing  that  has    vantages  to  the  student  of  anatomy,    ^"thezeaious 

mmmmsmsmmms 


specialist,,  i  lie  piai-cs,  «iY^"  ^  Vi  %i,ot  thp  mo^t 
cent  dissecli.-ns,  are  so  well  executed,  that  the  mo.t 
superficial  observer  cannot  fail  toPfreeive  the  por- 
tions, relations,  and  distinctive  features  o  the  jari 
ous  pkrts,  and  to  take  in  more  of  anatomy  at  a  glance 
than  by  rnany  long  hours  of  "l^l'Sent  stud>  over  he 
most  erudite  treatise,  or,  perhaps,  at  t  e  d'^^ectin 
table  itself.-ilfe^Z.  Journ.  of  N.  CaroUna,  Oct.  IboJ. 
For  this  truly  admirable  ^ork  the  profession  is 
indebted  to  the  cUstinguished  author  of  "Gra^  on 
the  Spleen."    The  vacancy  it  fills  has  been  longieit 


boneso  hT-h  ad  and  of  th.ir  development.  The 
studv  of  these  parts  is  thus  made  one  of  comparative 
ease^if  not  of  positive  pleasure ;  and  those  bugbears 
of  the  student  the  temporal  and  sphenoid  bones,  are 
shorn  o  half  heir  terrors.  It  is,  in  our  estimation, 
an  admirableaad  complete  text-book  for  the  student, 
^nd'a  uSul  work  of  reierence  f-  the  practitione  ; 
its  Dictorial  character  forming  a  novel  element,  to 
whFch  we  have  already  sufficiently  alluded.-4;n. 
Joiirn.  Med.  Set.,  July,  l=o9. 


18 


BL.ANCHARD    &    LEA'S    MEDICAL 


GIBSON'S  INSTITUTES  AND  PRACTICE  OF 
SURGERY.  Eighth  edition,  improved  and  al- 
tered. With  thirty- four  plates.  In  two  handsome 
octavo  volumes,  contain ino^  about  1,000  pages, 
leather,  raised  band  1.    $6  50. 

GARDxNER'S  MEDICAL  CHEMISTRY,  for  the 
use  of  Students  and  the  Profession.  In  one  royaj 
ISrno.  vol.,  cloth,  pp.  396,  with  wood-cuts.     $1. 

GLUGE'S  ATLAS  OF  PATHOLOGICAL  HIS- 
TOLOGY.     Translated,  with  Notes  and  Addi- 


tions, by  Joseph  Leidy,  M.  D.  In  one  volume, 
very  large  imperial  quarto,  extra  cloth,  witti  320 
copper-  plate  figures,  plain  and  colored,    $5  00. 

HUGHES-  INTRODUCTION  TO  THE  PRAC- 
TICE OF  AUSCULTATION  AND  OTHER 
MODES  OF  PHYSICAL  DIAGNOSIS  IN  DIS- 
EASES OF  THE  LUNGS  AND  HEART.  Se- 
cond edition  1  vol.  royal  lamo.,  ex.  cloih,  pp 
304.    f 1  00.  '  '  ^^ 


HAMILTON  (FRANK   H.),   M.  D., 
.    -.-^-,-,  .  ^r„^^  Professor  of  Surgery  in  the  University  of  Bufl\ilo,  &c. 

A  PEACTICAL  TREATISE  ON  FRACTUEES  AND  DISLOCATIONS.     In 

?>"„^„'i!!'"?-^"-'!.^.^"f'o"™®  octavo  volume,  oi  over  750  pages,  with  289  illustrations.   $4  25.    {Note 

illustrated,  which  will  be  a  desideratum  for  those 
practitioners  who  cannot  conveniently  see  the  mo- 
dels applied.— JVe?fl  York  Med.  Press,  Feb.  4,  1860. 

\ye  regard  this  work  as  an  honor  not  only  to  its 
author,  but  to  the  profession  of  our  country.  Were 
we  to  review  it  thoroughly,  we  could  not  convey  to 
the  mind  of  ihe  reader  more  forcibly  our  honest 
opinion  expressed  in  the  few  words— we  think  it  the 
best  book  ot  its  kind  extant.  Every  man  interested 
in  surgery  will  soon  have  this  work  on  his  desk. 
He  who  does  not,  will  be  the  loser.— iVew  Orleans 
Medical  News,  March,  1860. 

Now  that  it  is  before  us,  we  feel  bound  to  say  that 
much  as  was  expected  from  it,  and  onerous  as  was 
tlie  undertaking,  it  has  surpassed  expectation,  and 


Ready,  January,  1860.) 

This  is  a  valuable  contribution  to  the  surgery  of 
most  important  affections,  and  is  the  more  welcome, 
inasmuch  as  at  the  present  time  we  do  not  possess 
a  single  complete  treatife  on  Fractures  and  Dislo- 
cations in  the  English  language.  It  has  remained  for 
our  American  brother  to  produce  a  complete  treatise 
upon  the  subject,  and  bring  together  in  a  convenient 
form  those  alterations  and  improvements  that  have 
been  made  from  time  to  time  in  the  treatment  of  these 
affections.  One  great  and  valuable  feature  in  the 
work  before  us  is  the  fact  that  it  comprises  all  the 
improvements  introdu-ced  into  the  practice  of  both 
English  and  American  surgery,  and  though  far  from 
omitting  mention  of  our  continental  neighbors,  the 
author  by  no  means  encourages  the  notion— but  too 
prevalent  in  some  quarters- that  nothing  is  good 


unless  imported  from  France  or  Germany.      The  '.  achieved  more  than  was  pledged  in  its  behalf;  for 


latter  half  of  the  work  is  devoted  to  the  considera 
tion  of  the  various  dislocations  and  their  appropri- 
ate treatment,  and  its  merit  is  fully  equal  to  that  of 
the  preceding  portion.— TAe  London  Lancet, May  5, 
1860.  ' 

It  is  emphatically  the  book  upon  the  subjects  of 
which  it  treats,  and  we  cannot  doubt  that  it  will 
continue  so  to  be  for  an  indefinite  period  of  time. 
When  we  say,  however,  that  we  believe  it  will  at 
once  take  its  place  as  the  best  book  for  consultation 
by  the  practitioner;  and  that  it  will  form  the  most 
complete,  available,  and  reliable  guide  in  emergen- 
cies of  every  nature  connected  with  its  subjects;  and 
also  that  the  student  of  su  ■         '  ' 


its  title  does  not  express  in  full  the  richtess  of  its 
contents.  On  the  whole,  we  are  prouder  of  this 
work  than  of  any  which  has  for  years  emanated 
from  the  American  medical  press;  its  sale  will  cer- 
tainly be  very  large  in  this  country,  and  we  antici- 
pate its  eliciting  much  attention  in  Europe.— VasA- 
ville  Medical  Record,  Mar.  ISCO. 

Every  surgeon,  young  and  old,  should  possess 
himself  of  it,  and  give  it  a  careful  perusal,  in  doing 
which  he  will  be  richly  repaid. — St.  Louis  Med. 
and  Surg.  Journal,  March,  1S60. 

Dr.  Hamiltim  is  fortunate  in  having  succeeded  in 
filling  the  void,  so  long  felt,  with  what  cannot  fail 


Medical  and  Surgical  Journal,  March  1,  1860. 

The  work  is  concise,  judicious,  and  accurate,  and 
adapted  to  the  wants  of  the  student,  practiticner. 


one  of  their  number.  AVe  have  reason  to  be  proud 
of  it  as  an  original  work,  both  in  a  literary  and  sci- 
entific point  of  view,  and  to  esteem  it  as  a  valuable 


,,..  i  we  hope  that  it  may  soon 

vv  e  venture  to  say  that  this  is  not  alone  the  only  1  as  an  evideace  of  genuine 
complete  treatise  on  the  subject  m  the  language,  !  the  Atlantic,  and  further, 
Dut  the  best  and  most  practical  we  have  ever  read,  i  widely  known  at  home  as 


and  investigator,  honorable  to  the  author  and  to  the  '  Suide  in  a  most  difficult  and  important  branch  of 
profession.- C/iicag-o  Med.  JoitrMaZ,  March,  1860.      \  study  and  practice.     On  every  account,  therefore, 

we  hope  that  it  may  soon  be  widely  known  abroad 
ine  progress  on  this  side  of 
r,  that  It  may  be  still  more 

T,j,„„,.,  .         ..     , •• -■-■  ■^"«.     ..i^ely  known  at  home  as  an  authoritative  teacher 

xne  airangement  is  simple  and  systematic,  the  die-  '  from  which  every  one  may  profitably  learn,  and  as 
lion  Clear  and  graphic,  and  the  illustrations  nume-  ,  affording  an  example  of  honest,  well-directed,  and 
Tous  and  remarkable  for  accuracy  of  delineation.  I  untiring  industry  in  authorship  which  every  surgeon 
J  he  various  mechanical  appliances  are  faithfully  ■  may  enmlate.-  Am.  Med.  Journal,  April,  I860: 

HOBLYN  (RICHARD  D.),  M.  D. 
A  DICTIONARY  OP  THE  TERMS  USED  IN  MEDICINE  AND  THE 

COLLATERAL  SCIENCES.  A  new  American  edition.  Revised,  with  numerous  Additions, 
by  Isaac  Hays,  M.  D.,  editor  oi  the  "  American  Journal  of  the  JVledical  Sciences."  In  one  large 
royal  12mo.  volume,  leather,  of  over  500  double  columned  pages.     $1  50. 

th-^'H^'l''^'"^'*°'''u*"®''  ^"^^  student,  we  recommend  use;  embracing  every  department  of  medical  science 
tnis  aictionary  as  being  convenient  in  size,  accurate    down  to  the  very  latest  Aa.te.— Western  Lancet. 


in  definition,  and  sufficiently  full  and  complete  for 
ordinary  consultation.— CAar/eston  Med.  Journ. 


We  know  of  no  dictionary  better  arranged  and  ^ugnt,  aiwujs  u,  ue  upon  uie  s 
aaapted.  Itisnotencumbered  with  theobsoleteterms  Southern  Med.  and  Surg.  Journal. 
ot  a  bygone  age,  out  it  contains  all  that  are  now  ' 


Hoblyn's  Dictionary  has  long  been  a  favorite  with 
us.  It  is  the  best  book  of  definitions  we  have,  and 
ought  always   to   be  upon   the    student's  table. — 


HOLLAND'S  MEDICAL  NOTES  AND  RE- 
FLECTIONS. From  ihe  thiid  London  editum. 
In  one  handsome  octavo  volume,  extra  cloth.  $3. 

HORNER'S   SPECIAL   ANATOMY  AND   HIS- 


TOLOGY. Eighth  edition.  Extensively  revised 
and  modified.  In  two  large  octavo  volumes,  ex- 
tra cloth,  of  more  than  1000  pages,  with  over  300 
illustrations.    S6  00. 


HABERSHON  (S.  O.),  M.  D., 

■r^    Assistant  Physician  to  and  Lecturer  on  Materia  Medica  and  Therapeutics  at  Guv's  Hospital,  &c. 

PATHOLOGICAL   AND    PRACTICAL   OBSERVATIONS  ON  DISEASES 

O^  THE  ALIMENTARY  CANAL,  (ESOPHAGUS,  STOMACH,  CiECUM,  AND  INTES- 
TINES. With  illustrations  on  wood.  In  one  handsome  octavo  volume  of  312  pages,  extra 
cloth      $1  75.     {Now  Ready.)  ^  °     ' 


AND    SCIENTIFIC    PUBLICATIONS.  19 


HODGE  (HUGH    L.),   M.D., 

Professor  of  Midwifery  and  the  Diseases  of  Women  and  Children  in  the  University  of  Pennsylvania,  &c. 

ON  DISEASES  PECULIAR  TO  WOMEN,  incluclinc;  Displacements  of  the 
Uterus.  With  original  illustrations.  In  one  beautifully  printed  octavo  volume,  of  nearly  500 
pages.     {Noio  Ready.) 

The  profession  will  look  with  mucli  interest  on  a  volume  embodying  the  long  and  extensive  ex- 
r)enence  of  Professor  Hodge  on  an  important  branch  of  practice  in  which  his  opportunities  for 
inve«tio-ation  have  been  so  extensive.  A  short  summary  of  the  contents  will  show  ihe  scope  of 
the  wo*rk  and  the  manner  in  which  the  subject  is  presented.  It  will  be  seen  that,  with  the  excep- 
tion of  Displacements  of  the  Uterus,  he  divides  the  Diseases  peculiar  to  Women  into  two  great 
constitutional  classes— those  arising  from  irritation,  and  those  arising  from  sedation. 

CONTENTS. 
PART  I  Diseases  of  Irritation.— Chapter  I.  Nervous  Irritation,  and  its  Consequences —II. 
Irritable  Uterus.- III.  Local  Symptoms  of  Irritable  Uterus:  Menorrliagia  and  Hsemorrhogia; 
Leucorrhffia;  Dysmenorrlioea -IV.  Local  Symptoms  of  Irritable  Uterus;  Complications.-V. 
General  Svn  ptoms  of  Irritable  Uterus  :  Cerebro-spinil  Irritations.-^  I.  General  Syniptoms  oi 
L-r  table  Uierus.-VII.  Progress  and  Results  of  Irritable  Uterus.-VIJI.  Causes  and  Pathology 
of  Irritable  Diseases  —IX.  Treatment  of  Irritable  Uterus;  Removal  or  Palliation  of  the  Cause. 
-XTreartnenl  of  Irritable  Uterus:  To  Diminish  or  Destroy  the  Morbid  Irritability -XI 
Treatment  of  the  Complications  of  Irritable  Uterus.-XII,  Treatment  of  the  Complications  of 
Irritable  Uterus. 

PART  II  Displacements  of. the  Uterus.-Chapter  I.  Natural  Position  and  Supports  of  the 
Uterus  -II  Varieties  of  Displacements  of  the  Uterus,  and  their  Causes.-III.  Symptoms  of 
dIo  acements  of  the  Uterus.-lV.  Treatment  of  Displacements  of  the  Uterus.-V  Treatment 
?f^'pra^emen°;;  mternal  Supports.-VI.  Treatment  of  Displacement's  ;  Lever  Pessanes^- 
VII  T  ea'ment  of  the  Varieties  of  Displacemcnts.-VIH.  Treatment  of  Comphca  ions  of  Dis- 
placemeS  ot  the  Uterus.-IX.  Treatment  of  Enlargements  and  Displacements  ot  the  Ovaries,  &c 

PAKT  TTl    DiSFA-^ES  OF  Sedation.-Chapter  I.  Sedation  and  its  Consequences :  Organic  and 
Nervous  Sed^ton;    Passive  Congestion;   Reaction;  Treatment -II    Sedation  of  the  Uterus 
2meno"rhoea:  Sed'ation  of  the  Uterus  from  Moral  Causes ;  Sedation  of  the  Uterus  from  Physical 
Causes— III.  Diagnosis  and  Treatment  of  Sedation  of  the  Uterus. 
The  illustrations,  which  are  all  original,  are  drawn  to  a  uniform  scale  of  one-half  the  natural  size. 

JONES  (T.  WHARTON),   F.  R.  S., 

Professor  of  Ophthalmic  Medicine  and  Surgery  in  University  College,  London,  &o. 

^?lDL\^S^^wit!!L^^^^^^ 

JONES  rc.  HANDFIELD),  F.  R.  S.,  8.  EDWARD  H.  SIEVEKJNG,  M.O., 
Assistant  Physicians  and  Lecturers  in  St.  Mary's  Hospital,  London. 

A  MANIT\L  OF  PATHOLOGICAL  ANATOMY.    First  American  Edition 

\ev^ed.^  wlihVhree  hunLd  and  ninety-seven  handsome  wood  engravmgs.    In  one  large  and 
beautiful  octavo  volume  of  nearly  750  pages,  leather.    $3  7d. 

oblio-ed  to  glean  from  a  great  number  of  monographs, 
and  Uie  field  was  so  extensive  that  but  few  cultivated 
it  with  any  decree  of  success     As  a  s  mple  work 


As  a  concise  text-book,  containing,  m  a  condensed 
form,  a  complete  outline  of  what  is  known  m  the 
domain  of  Pathological  Anatomy,  it  is  perhaps  the 
best  work  in  the  English  language.  Its  great  merit 
consists  in  its  completeness  and  brevity,  and  m  this 
respect  it  supplies  a  great  ^'f-sideratum  in  our  lite- 
rature.   Heretofore  the  student  of  pathology  was 


t,VyeV:ren7e,"ri^e;efo7e  ItlTof  great  valae  to  the 
student  of  pathological  anatomy,  and  should  be  in 
every  physician's  library  .-W'e^iem  Lancet. 


KIRKES  (WILLIAM  SENHOUSE),   M.  D., 

Demonstrator  ofMorbid  Anatomy  at  St.  Bartholomew's  Hospital,  &c. 

A    MANUAL   OF    PHYSIOLOaY.      A  now  A..e^^^^^^^ 

is^^^i^  tatSnp.™  vTorsi^ss^-) 

12mo.  volume,  leavner.     VV  One  of  the  very  best  handbooks  of  Physiology  we 

.      .  :. ,„!,    ,,r,r.rnvpH  edition  of  UUe  Ul  LUC  V ci  >  >/  „„  „„»i;,,o  .if  HiB  Ef-l- 


This  is  a  new  and  very  much  imP'-^ed  «  '  Pf^f 
Dr.  Kirkes'  well-kn..wn  Handbook  of  Ph>/'"l"g,y- 
It  combines  c.mciseness  with  completeness  and  is 
therefore,  admirably  adapted  for  consultation  by  the 
busy  practitioner.-Di«6HM  Quarterly  Journal. 

Its  excellence  is  in  its  compactness,  its  clearness 
and  its  carefully  cited  authorities.  ^1^'^  the  most 
convenient  of  text-books.  These  gentlemen  Messrs^ 
Kirkes  and  Paget,  have  really  an  immense  talent^for 
silence,  whicli^is  not  so  common  or  so  cheap  as  prat 
ing  people  fancy.  They  have  the  gi/t  of  tellin  us 
wLt  we  want  to  know,  without  'l^^^^^^X^^a 
sary  to  tell  us  all  they  ^uo^.-Boston  Mea.  ana 
Surg.  Journal. 


fSne  ot  me  very  uc&l  iitiiin.jv'"""  ■-■*    — j  o^ 

nossess-presenting  just  such  an  outline  of  t!ie  sci- 
ence as  the  student  requires  during  his  attendance 
upon  a  course  of  lectures,  or  for  reterence  whilst 
rrpaiing  for  examinati.m.-^m.  Medical  Journal. 

For  the  student  beginning  this  study,  and  the 
nractitioner  who  has  but  leisure  to  refresh  hia 
memo  'this  book  is  invaluable  as  it  con  ains  all 
hlut  is  important  to  know,  without  special  details, 
whch  are  read  with  interest  only  by  those  who 
w  uld  make  a  specialty,  or  desire  to  possessa  cnti- 
cal  knowledge  of  the  suhieet—Charlesion  Med. 
Journal. 


20 


BLANCHARD  &  LEA'S  MEDICAL 


KNAPP'S  TECHNOLOGY ;  or,  Chemistry  applied 
to  tJie  Arts  and  to  Manufactures.  Edited  by  Dr 
KoNALDs,  Dr.  Richardson,  and  Prof.  W  r' 
Johnson.  In  two  handsome  8vo.  vols.,  withabout 
500  wood  engravings.    $6  00. 


HTS?*^^^'^    LECTURES    ON    THE    PRINCI- 
PLES  AND   METHODS   OF    MEDICAL   OR 
SERVATION  AND  RESEARcA''  Fo^^he  Us; 
of  Advanced  Students  and  Junior  Practitioners 
In  one  royal  12mo.  volume,  extra  cloth.  Price  $l! 


A      T,T,  A /^.mx^  .  ^  LALLEMAND  AND   WILSON. 

A    PRACTICAL    TREATISE    ON    THE    CAUSES     SYMPTOMq     avtv 

TREATMENT  OF  SPERMATORRHfFA      pTrM   7  '     ^-*^  ^^^-t^-^'JJWb,     AND 

WiLsoN,M.D.    In  one  neat  octavo  vohmie,  of  about  400  pp.,  extra  cloth.  ^2  00.  (JusVlssuS^ 
YTTiiTT/^  L.A   ROCHE  (R.),    M.D.    5tc 

S.     T-  ^?T^.^'  considered  in  its  Historical,  'Pathological,  Etiolomcal    and 

handsome  octavo  volumes^of  nearly  1500  piys!extri  doth      J^'OO     ^''"'-    ^"  ^^"  ^"^^"  ^""^ 
From  Professor  S.  H.  Dickson,  Charleston,  S.  C 
September  18,  1855.  ' 

A  monument  of  intelligent  and  well  applied  re 


search,  almost  without  example.  It  is,  mdeed,'[n 
Itself,  a  large  library,  and  is  destined  to  constitute 
the  special  resort  as  a  book  of  reference,  in  the 
subject  of  which  it  treats,  to  all  future  time. 

We  have  not  time  at  present,  engaged  as  we  are, 
by  day  and  by  night,  in  the  work  of  combating  this 
very  disease,  now  prevailing  in  our  city,  to  do  more 
>,s  .frinTf  t  V,^  cursory  notice  of  what  we  consider 
as  undoubtedly  the  most  able  and  erudite  medical 
publication  our  country  has  yet  produced.  But  in 
view  of  the  startling  fact,  that  this,  the  most  malig- 


nant and  unmanageable  disease  of  modern  times, 
has  for  several  years  been  prevailing  in  our  country 
o  a  greater  extent  than  ever  before:  that  it  is  no 
longer  confined  to  either  large  or  small  cities,  but 
penetrates  country  villages,  plantations,  and  farm- 
houses; that  it  IS  treated  with  scarcely  better  suc- 
cess now  than  thirty  or  forty  years  ago  ;  that  there 
IS  vast  mischief  done  by  ignorant  pretenders  to  know- 
ledge in  regard  to  the  disease,  and  m  view  of  the  pro- 
bability that  a  majority  of  southern  physicians  will 
be  called  upon  to  treat  the  disease,  we  trust  that  this 
able  and  comprehensive  treatise  will  he  very  o-ene- 
rally  read  m  the  south.— MewzpAw  Med.  Recorder 


BY  THE  SAME  AUTHOR. 

»™KrML''f-  ^""^T"^  Connection,  Pathological  and  Etiological,  with  Au- 

L=,!^r„T«vr4ts,":i"rsCof  So  sr 'sTS  "-^'^  ^«^«^  -^  «»'""■  '■ »- 

.     ,^  LUDLOW  (J.   LJ,   M.  D 

A  MANUAL   OF    EXAMINATIONS   upoA  Anatomy,   Physiology    Surgery 

study  or  rSence  i^  Jj'^ '"«<='^a»'°'^l  execution  to  render  it  a  convenient  and  satisfaci;ry  book  fo^ 
espeliaVv  ?uited  forTh.  offi-f"^^*'™''"*  *"/•  '^'^  T^'^f^  '»  the  form  of  question  and  answer  renders  it 
especially  .uited  for  the  office  examination  of  students  and  for  those  preparing  for  graduation 

duTLVreZurrspturtrr:curr"erlm  I  '^^^'^^^  ^-^o  Ms  ^e., J^y  the  various  professors  to 

fresh,\t  a  glance, 'his  m"emor;^of"[.e7r.To;ju;ic;  |  Mari857."  "'"'"'''''  ''  hsten.-Western  Lancet, 

-r,^^^^  LEHMANN   (0.  G.) 

Jau     /  ^*  °^  Physio  ogical  Chemistry,  and  an  Appendix  of  plates.     Complete  in  two  larie 
tra'tions'^SVo''"'  ''^""'''  '"^"  '^°^''  '-^^'-'^^^^1200  page?  with  neaH^two  CS  iHu's- 

mo^s^^cor^r^ehi^tro-k  ^^r^^^^r^L^^!;^  \  PhTsfon^rcSLT't^^^r.^rwri  '^ 

t  on  extant  on  every  branch  of  the  subject  on  which     mceTjin   1856  ^  '^'"'""'^  ^"^-  ^''' 

^^"^•Ais.— Edinburgh  Journal  of  Medical  Science.] 

BY  THE  SAME  AUTHOR.      (Lately  PuUisJied.) 

MANUAL  OF  CHEMICAL   PHYSIOLOGY.      Translated  from  the  German 

with  Note,  and  Additions,  by  J.  Cheston  Morris,  M.  D.,  with  an  IntroducZv  Es.^v  on  Vh^l 
Force,  by  Professor  Samuel  Jackson,  M.  D.,  of  the  UniVersitv  of  Penniv  vZ;r  w?^  u 
trations  on  wood.     In  one  very  handsUe  oclavo  rolumTextS  c^oth  of  sS  pages.  ^2  25  "'" 
T„  „  J     .■      ,.      ,       „        F^otnProf.  Jacksoti's  hitroductory  Essay . 
student  Whin  ''""^^'r''  ^^  ^'  ^"^'""""  ^^  ^  '"^""^l  ^^  Organic^6hemistry  for  the  use  of  the 
fortheS  more  rSrSie"VhVhtrvT''"A'"  ''"'^^'"l'  ^°^'^.'^^  Physxol Jo  °caI  Chemistry 

my  in  that  i^^zt!^:^:^c:i'ti^^£^.  '^^^ti^'^^^r^  -^-''^  «^  ^^^  -^^- 


AND    SCIENTIFIC    PUBLICATIONS. 


21 


LAWRENCE  (W.),  F.  R.  S.,  &c. 
A  TREATISE    ON   DISEASES    OF   THE    EYE.     A    new  edition,  edited, 

with  numerous  additions,  and  243  illustrations,  by  Isaac  Hays,  M.  D.,  Surgeon  to  Will's  Hospi- 
tal, &c.  In  one  very  large  and  handsome  octavo  volume,  of  950  pages,  strongly  bound  in  leatner 
with  raised  bands.     $5  00. 

MEIGS  (CHARLES  D.),  M.  D., 

Professor  of  Obstetrics,  &c.  in  the  .TetTerson  Medical  College,  Philadelphia.  ^ 

OBSTETRICS :  THE   SCIENCE   AND  THE   ART.    Third  edition,  revised 

and  improved.  With  one  hundred  and  twenty-nine  illustrations.  In  one  beautifully  prmted  octavo 
volume,  leather,  of  seven  hundred  and  fifty-tvro  large  pages.     $3  75. 

The  rapid  demand  for  another  edition  of  this  work  is  a  sufficient  expression  of  the  favorable 
verdict  of  he  profession.  In  thus  preparing  it  a  third  time  for  the  press,  the  author  has  endeavored 
to  render  it  in  every  respect  worthy  of  the'favor  which  it  has  received.  To  accomplish  this  he 
has  thorougWy  Revised  it  in  every  part.  Some  portions  have  been  rewritten  others  added  new 
mu«tratTons  hive  been  in  many  instances  substituted  for  such  as  were  not  deemed  satisfactory, 
white  bv  an  aklraiTon  in  the  typographical  arrangement,  the  size  of  the  work  has  not  been  increased, 
Tnd  the  Ke  remairunalterld.  "  In  its  present  improved  form,  it  is,  therefore,  hoped  that  the  work 
will  conS  to  meet  the  wants  of  the"^  American  protession  as  a  sound,  practical,  and  extended 
System  of  Midwifery.  . 

Though  the  work  has  received  only  five  pages  of       The  .^f  «*  Ame"can  work  on  m^^^^^ 
enlareement,  its  cliapters  throughout  wear  the  im-    accessible  to  the  student  and  pi actitioner 
press  of  careful  revision.   Expunging  and  rewriting,    Med.  and  Surg.  Journal,  Jan.  1857. 
remodellino-  its  sentences,  with  occasional  new  ma-        This  is  a  standard  work  by  a  great  American  UD- 
terial   all  evince  a  lively  desire  that  it  shall  deserve    gtetrician.     It  is  the  third  and  last  edition,  and,  in 
to  be'reo-arded  as  improved  in  manner  as  well  as    the  larguage  of  the  preface,  the  author  lias  "brougni 
matter    "in  the  jnatter,  every  stroke  of  the  pen  has    j^e  subject  up  to  the  latest  dates  of  real  improve- 
inereased  the  value  of  the  book,  both  in  expungings    n^ent  in  our  art  and  Science."— Nashville  Journ.  oj 
and  additions  -—Western  Lancet,  Jan.  1857.  |  M^a.  and  Surg.,  May,  1857. 

BY  THE  SAME  AUTHOR.     (Just  Issued.)  .    „     .         -T 

WOMAN.  HER  DISEASES  AND  THEIR  REMEDIES.    A  Series  of  Lec^ 

^St^is  ^as?  Fourth  tdlmp^ved  edition.    In  one  large  and  beautifully  printed  octavo 
volume,  leather,  of  over  700  pages.     $3  60._         ^^^^  ^^ ^^  ^^^^^^^  ^^^^^^^^  .^ ^  ^^ 

agreeable  manner.-Si.Xom*  Med.  and  Surg.  Jour. 
There  is  an  off-hand  fervor,  a  glow,  and  a  warm- 
lieartedness  infecting  the  effort  of  Dr.  Meigs,  which 
is  entirely  captivating,  and  which  absolutely  hur- 
ries the  reader  through  from  beginning  to  end.  ue- 
sides,  the  book  teems  with  solid  instruction,  and 
it  shows  the  very  highest  evidence  of  ability,  viz., 
the  clearness  with  which  the  information  is  pre- 
sented. We  know  of  no  better  test  of  one's  under- 
standing a  subject  than  the  evidence  of  the  power 
of  "ucWly  explaining  it.  The  most  elementary,  as 
wel"  as  the  obscurest  subjects,  under  the  penci  of 
Prof  Mei°-s,  are  isolated  and  made  to  stand  out  in 
suchbold  relief,  as  to  produce  distinct  miPfessions 
upon  the  mind  and  memory  of  the  reader. -T/k) 
Charleston  Med.  Journal. 

Professor  Meigs  has  enlarged  and  amended  this 
ffreat  work,  for  such  it  unquestionably  is,  having 
llssed  the  ordeal  of  criticism  at  home  and  abroad 
but  been  improved  thereby  i  for  in  this  new  edition 
r  aXhor.Ls  introduced  real  improveniens    and 


In  other  respects,  in  our  estimation,  too  much  can- 
not be  SRid  in  praise  of  this  work.  It  abounds  with 
beautiful  passages,  and  for  conciseness,  for  origin- 
ality, and  for  all  that  is  commendable  m  a  wo  k  on 
the  diseases  of  females,  it  is  not  excelled,  and  pro- 
bably  not  equalled  in  the  English  language.  On  the 
whole,  we  know  of  no  worK  on  the  diseases  of  wo- 
men which  we  can  so  cordially  commend  to  the 
student  and  practitioneras  the  one  before  us.— O/iio 
Med.  and  Surg.  Journal. 

The  body  of  the  book  is  worthy  of  attentive  con- 
sideration, and  is  evidently  the  production  ot  a 
clever,  thoughtful,  and  sagacious  physician.  iJr. 
Mei'^s's  letters  on  the  diseases  of  the  external  or- 
ganl,  contain  many  interesting  and  rare  cases,  anU 
Lny  instructive  observations.  We  take  our  leave 
of  Dr.  Meigs,  with  a  high  opinion  of  his  talents  arid 
originality  —r/ic  British  and  Foreign  Medtco-tht- 
rurgical  Review. 

Every  chapter  is  replete  with  practical  instruc- 
tion, and  bears  the  impress  of  being  the  composition 

of  aA  acute  and  experienced  mind.     There  is  a  terse-  ,  the  author  has  inrruuue.u..j.....^^^^  .^ 

ness,  and  at  the  same  tune  an  accuracy  in  his  de-     increased  the  value  and  utiiuy 
scription  01  symptoms,  and  in  the  rules  for  diagnosis,     measurab  y      I     P^^^^^"'^^^^  aTex^beranc'e  of  Sew 
which  cannot  fail  to  recommend  the  volame  to  the      „d  ^P"''!^!  "\""f^;''page;  that  we  confess  our- 
attention  of  the  reaier. -RanHng's  Abstract  ^^^fp^To  Lave  beco'L'  clamored  with    the  book 

Iteontams  a  vast  amount  of  practical  l^now  edge,    sehes   w  n  v  ^^^^^  withhold  our  congratu- 

by  one  who  has  accurately  "'^^"^^d  and  retained    anJ  its  ^™^,  Philadelphia  confreres    that  such  a 
the  experience  of  many  yeais.-r-Bubim  Quarterly  |  ^^^I2lx\lin  tlieir  service.-iV.  Y.  Med.  Gazetts. 
Journal.  .,,.r^n-a 

^      oTnl?J''\'Mn    TREATMENT    OF    CHILDBED 
ON    THE    NATURE,    SIGNS,    ^^D  JREAi^f  ,2  ciasV^^ 

FEVER.     In  a  Series  of  Letters  addressed  to  the  Students 
octavo  volume,  extra  cloth,  of  365  pages.     $2  50 


The  Instructive  and  interesting  f^^^^ff^.f^  *^^' 
work,  whose  previous  labors  have  placed  his  coun^ 
tryme'n  under  deep  and  abiding  obhjations  again 
challenges  their  admiration  m  the  fresh  and  v^S" 
OUB,  attractive  and  racy  pages  before  us.   It  is  a  ue 


i^otnhlp  book    *    *    *   This  treatise  upon  child- 

o'el^ry  Vac    AZT^^io  scorn^  to  lag  in  the  rear.- 
mlhviUe  Journal  of  Medicine  and  Surgery. 


,  attractive  and  racy  pages  Detore  UH.   ...=  «."^  ..„  ..nrnTLVD  PLATES. 

BY  THE  SAME  ^i^^«°i^  =  ^"^r^TSASBS  OF  THE  NECK 
A  TREATISE  ON  ACUTE  ^ND  CHRON  C^^^^^^^ 

liyo^St^^lSanirocrrvVur^^^^^^^^^  *4  50. 

style  01  an.  7777TTir-S!V'=^  OPERATIVE  SURGERY,  based 


22 


BLANCHARD    &   LEA'S    MEDICAL 


MACLISE  (JOSEPH),    SURGEON. 
SURGrlCAL  ANATOMY.     Forming  one  volume,   very  large  imperial  quarto. 

With  sixty-eight  large  and  splendid  Plates,  drawn  in  the  best  style  and  beautifully  colored.    Con- 
taining one  hundred  and  ninety  Figures,  many  of  them  the  size  of  life.     Together  with  copious 
and  explanatory  letter-press.     Strongly  and  handsomely  bound  in  extra  cloth,  being  one  of  the 
cheapest  and  best  executed  Surgical  works  as  yet  issued  in  this  country.    $11  00. 
*^*  The  size  of  this  work  prevents  its  transmission  through  the  post-office  as  a  v.'hole,  but  those 

who  desire  to  have  copies  forwarded  by  mail,  can  receive  them  in  five  parts,  done  up  in  stout 

wrappers.    Price  $9  00. 


One  of  the  greatest  artistic  triumphs  of  the  age 
in  Surgical  Anatomy. — British  American  Medical 
Journal. 

No  practitioner  whose  means  will  admit  should 
fail  to  possess  it. — Ranking's  Abstract, 

Too  much  cannot  be  said  in  its  praise ;  indeed, 
we  have  not  language  to  do  it  justice. — Ohio  Medi- 
cal and  Surgical  Journal. 

The  most  accurately  engraved  and  beautifully 
colored  plates  we  have  ever  seen  in  an  American 
book — one  of  the  best  and  cheapest  surgical  works 
ever  published. — Buffalo  Medical  Journal. 

It  is  very  rare  that  so  elegantly  printed,  so  well 
illustrated,  and  so  useful  a  work,  is  offered  at  so 
moderate  a  price. — Charleston  Medical  Journal. 

Its  plates  can  boast  a  superiority  which  places 
them  almost  beyond  the  reach  of  competition. — Medi- 
cal Examiner . 

Country  practitioners  will  find  these  plates  of  im- 
mense value. — N.  Y.  Medical  Gazette. 


A  work  which  has  no  parallel  in  point  of  accu- 
racy and  cheapness  in  the  English  language. — N.  Y. 
Journal  of  Medicine. 

We  are  extremely  gratified  to  announce  to  the 
profession  the  completion  of  this  truly  magnificent 
work,  which,  as  a  whole,  certainly  stands  unri- 
valled, both  for  accuracy  of  drawing,  beauty  of 
coloring,  and  all  the  requisite  explanations  of  the 
subject  in  hand. — Thi  New  Orleans  Medical  and 
Surgical  Journal. 

This  is  by  far  the  ablest  work  on  Surgical  Ana- 
tomy that  has  come  under  our  observation.  We 
know  of  no  other  work  that  would  justify  a  stu- 
dent, in  any  degree,  for  neglect  of  actual  dissec- 
tion. In  those  sudden  emergencies  that  so  often 
arise,  and  which  require  the  instantaneous  command 
of  minute  anatomical  knowledge,  a  work  of  this  kind 
keeps  the  details  of  the  dissecting-room  perpetually 
fresh  in  the  memory. — The  Western  Journal  of  Medi- 
cine and  Surgery. 


MILLER  (HENRY),  M.  D., 

Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  the  University  of  Louisville. 

PRINCIPLES  AND  PRACTICE  OF  OBSTETRICS,  &c. ;  including  the  Treat- 

ment  of  Chronic  Inflammation  of  the  Cervix  and  Body  of  the  Uterus  considered  as  a  frequent 
cause  of  Abortion.  Witb  about  one  hundred  illustrations  on  wood.  In  one  very  handsome  oc- 
tavo volume,  of  over  600  pages.     (Lately  Published.)    $3  75. 

The  reputation  of  Dr.  Miller  as  an  obstetrician  is  too  widely  spread  to  require  the  attention  of 
the  profession  to  be  specially  called  to  a  volume  containing  the  experience  of  his  long  and  extensive 
practice.  The  very  favorable  reception  accorded  to  his  "  Treatise  on  Human  Parturition,"  issued 
some  years  since,  is  an  earnest  that  the  present  work  will  fulfil  the  author's  intention  of  providing 
within  a  moderate  compass  a  complete  and  trustworthy  text-book  for  the  student,  and  book  of  re- 
ference for  the  practitioner. 

We  congratulate  the  author  that  the  task  is  done.  I  tion  to  which  its  merits  justly  entitle  it.  The  style 
We  congratulate  him  that  he  has  given  to  the  medi-  is  such  that  the  descriptions  are  clear,  and  each  sub- 
cal  public  a  work  -which  will  secure  for  him  a  high  '  ject  is  discussed  and  elucidated  with  due  regard  to 
and  permanent  position  among  the  standard  autho-  i  its  practical  bearings,  which  cannot  fail  to  make  it 
rities  on  the  principles  and  practice  of  obstetrics. 
Congratulations  are  not  less  due  to  the  medical  pro- 
fession of  this  country,  on  tlie  acquisition  of  a  trea- 
tise embodying  the  resul  ts  of  the  studies,  reflections, 
and  experience  of  Prof.  Miller.  Few  men,  if  any, 
in  this  country,  are  more  competent  than  he  to  write 
on  thisdepartmentof  medicine.  Engaged  for  thirty- 
five  years  in  an  extended  practice  of  obstetrics,  for 
many  years  a  teacher  of  this  branch  of  instruction 
in  one  of  the  largest  of  our  institutions,  a  diligent 
student  as  well  as"a  careful  observer,  an  original  and 
independent  thinker,  wedded  to  no  hobbies,  ever 
ready  to  consider  without  prejudice  new  views,  and 
to  adopt  innovations  if  they  are  really  improvements, 
and  withal  a  clear,  agreeable  writer,  a  practical 
treatise  from  his  pen  could  not  fail  to  possess  great 
value. — Buffalo  Med  Journal,  Mar.  1858. 

In  fact,  this  volumemust  take  its  place  among  the 
standard  systematic  treatises  on  obstetrics  ;  a  posi- 


acceptable  and  valuable  to  both  students  and  prac- 
titioners. We  cannot,  however,  close  this  brief 
notice  without  congratulating  the  author  and  the 
profession  on  the  production  of  such  an  excellent 
treatise.  The  author  is  a  western  man  of  whom  we 
feel  proud,  and  we  cannot  but  think  that  his  book 
will  find  many  readers  and  vrarm  admirers  wherever 
obstetrics  is  taught  and  studied  as  a  science  and  an 
art. — The  Cincinnati  Lancet  and  Observer.,  Feb.  1858, 
A  most  respectable  and  valuable  addition  to  our 
home  medical  literature,  and  one  reflecting  credit 
alike  on  the  author  and  the  institution  to  which  he 
is  attached.  The  student  will  find  in  this  work  a 
most  useful  guide  to  his  studies ;  the  country  prac- 
titioner, rusty  in  his  reading,  can  obtain  from  its 
pages  a  fair  resume  of  the  modern  literature  of  the 
science ;  and  we  hope  to  see  this  American  produc- 
tion generally  consulted  by  the  profession. — Va, 
Med.  Journal,  Feb.  1858. 


MACKENZIE   (W.),    M.D., 

Surgeon  Oculist  in  Scotland  in  ordinary  to  Her  Majesty,  &c.  &c. 

A  PRACTICAL   TREATISE  ON   DISEASES   AND  INJURIES  OF   THE 

EYE.  To  which  is  prefixed  an  Anatomical  Introduction  explanatory  of  a  Horizontal  Section  of 
the  Human  Eyeball,  by  Thomas  Wharton  Jones,  F.  R.  S.  From  the  Fourth  Revised  and  En- 
larged London  Edition.  With  Notes  and  Additions  by  Addinell  Hewson,  M.  D.,  Surgeon  to 
Wnis  Hospital,  &c.  &c.  In  one  very  large  and  handsome  octavo  volume,  leather,  raised  bands,  with 
plates  and  numerous  wood-cuts.     $5  25. 


The  treatise  of  Dr.  Mackenzie  indisputably  holds 
the  first  place,  and  forms,  in  respect  of  learning  and 
research,  an  Encyclopaedia  unequalled  in  extent  by 
any  other  work  of  the  kind ,  ei  ther  English  or  foreign . 
— Dixon  on  Diseases  of  the  Eye. 

Few  modern  books  on  any  department  of  medicine 
or  surgery  have  met  with  such  extended  circulation, 
or  have  procured  for  their  authors  a  like  amount  of 
European  celebrity.  The  immense  research  which 
it  displayed,  the  thorough  acquaintance  with  the 
fubject,  practically  as  well  as  *' '"*''>aHy,and  the 


able  manner  in  which  the  author's  stores  of  learning 
and  experience  were  rendered  available  for  general 
use,  at  once  procured  for  the  first  edition,  as  well  on 
the  continent  as  in  this  country,  that  high  position 
as  a  standard  work  which  each  successive  edition 
has  more  firmly  established.  We  consider  it  the 
duty  of  every  one  who  has  the  love  of  his  profession 
and  the  welfare  of  his  patient  at  heart,  to  make  him- 
self familiar  with  this  the  most  complete  work  in 
the  English  language  upon  the  diseases  of  the  eye. 
— Med.  Times  and  Gazette. 


AND    SCIENTIFIC    P  LTBLIC  ATI  ONS. 


23 


MILLER  (JAMES),   F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Edinburgh,  &e. 

PRINCIPLES  OF  SURGERY.     Fourth  American,  from  the  third  and  revised 

Edinburgh  edition.    In  one  large  and  very  beautiful  volume,  leather,. of  700  pages,  with  two 

hundred  and  forty  illustrations  on  wood.     $3  75. 

The  work  of  i\Ir.  Miller  is  too  well  and  too  favor- 
ably known  among  us,  as  one  of  our  best  text-books, 
to  render  any  further  notice  of  it  necessary  than  the 
announcement  of  a  new  edition,  the  fourth  in  our 


country,  a  proof  of  its  extensive  circulation  among 
us.  As  a  concise  and  reliable  exposition  of  the  sci- 
ence of  modern  surgery,  it  stands  deservedly  high — 

we  know  not  its  superior Boston  Med.  and  Surg. 

Journal. 


The  work  takes  rank  with  Watson's  Practice  of 
Physic ;  it  certainly  does  not  fall  behind  that  great 
work  in  soundness  of  principle  or  depth  of  reason- 
ing and  research .  No  physician  who  values  his  re- 
putation, or  seeks  the  interests  of  his  clients,  can 
acquit  himself  before  his  God  and  the  world  without 
making  himself  familiar  with  the  sound  and  philo- 
sophical views  developed  in  the  foregoing  book. — 
New  Orleans  Med.  and  Surg.  Journal. 
BY  THE  SAME  AUTHOR.    (Just  Issued.) 

THE   PRACTICE   OF   SURGERY.      Fourth  American  from  the  last  Edin- 

burgh  edition.    Eevised  by  the  American  editor.     Illustrated  by  three  hundred  and  sixty-four 

engravings  on  wood.     In  one  large  octavo  volume,  leather,  of  nearly  700  pages.     $3  75. 

No  encomium  of  ours  could  add  to  the  popularity  |  his  works,  both  on  tne  principles  and  practice  of 

of  Miller's  Surgery.    Its  reputation  in  this  country  i  surgery  have  been  assigned  the  highest  rank.     If  we 

is  unsurpassed  by  that  of  any  other  work,  and,  when  |  were  limited  to  but  one  work  on  surgery,  that  one 


taken  in  connection  with  the  author's  Prhiciples  of 
Surgery,  constitutes  a  whole,  without  reference  to 
to  which  no  conscientious  surgeon  would  be  willing 
practice  his  art. —  Southern  Med.  and  Surg.  Journal. 
It  is  seldom  that  two  volumes  have  ever  made  so 
profound  an  impression  in  so  short  a  time  as  the 
''  Principles"  and  the  "  Practice"  of  Surgery  by 
Mr.  Miller — or  so  richly  merited  the  reputation  they 
have  acquired.  The  author  is  an  eminently  sensi- 
ble, practical,  and  well-informed  man,  who  knows 


should  be  Miller's,  as  we  regard  it  as  superior  to  all 
others. — St.  Louis  Med,  and  Surg.  Journal. 

The  author  has  in  this  and  his  "  Principles,"  pre- 
sented to  the  profession  one  of  the  most  complete  and 
reliable  systems  of  Surgery  extant.  His  style  of 
writing  is  original,  impressive,  and  engaging,  ener- 
getic, concise,  and  lucid.  Few  have  the  faculty  of 
condensing  so  much  in  small  space,  and  at  the  same 
time  so  persistently  holding  theattention.  "Whether 
as  a  text-book  for  students  or  a  book  of  reference 


exactly  what  he  is  talking  about  and  exactly  how  to  [  f^,,.  practitioners,  it  cannot  be  too  strongly  reeom- 
talk  \t.— Kentucky  Medical  Recorder.  mfnAt A. —Southern  Journal  of  Med.  and  Physical 

By  the  almost  unanimous  voice  of  the  profession,  |  Sciences. 


MORLAND  (W.  W.),    M.   D., 

Fellow  of  the  Massachusetts  Medical  Society,  &c. 

DISEASES  OF  THE  URINARY  ORGANS ;  a  Compendium  of  their  Diagnosis, 

Pathology,  and  Treatment.    With  illustrations.     In  one  large  and  handsome  octavo  volume,  of 
about  600  pages,  extra  cloth.     {Just  Issued.)    $3  50. 


Taken  as  a  whole,  we  can  recommend  Dr.  Nor- 
land's compendium  as  a  very  desirable  addition  to 
the  library  of  every  medical  or  surgical  practi- 
tioner.— Brit,  and  For.  Med.-Chir.  Rev.,  April,  1859. 

Every  medical  practitioner  whose  attention  has 
been  to  any  extent  attracted  towards  the  class  of 
diseases  to  which  this  treatise  relates,  must  have 
often  and  sorely  experienced  the  v/ant  of  some  full, 
yet  concise  recent  compendium  to  which  he  could 
refer.  This  desideratum  has  been  supplied  by  Dr. 
Morland,  and  it  has  been  ably  done.  He  has  placed 
before  us  a  full,  judicious,  and  reliable  digest. 
Each  subject  is  treated  with  sufficient  minuteness. 


yet  m  a  succinct,  narrational  style,  such  as  to  render 
the  work  one  of  great  interest,  and  one  which  will 
prove  in  the  highest  degree  useful  to  the  general 
practitioner.  To  themembersof  iheprofessionin  the 
country  it  will  be  peculiarly  valuable,  on  account 
of  the  characteristics  which  we  have  mentioned, 
and  the  one  broad  aim  of  practical  utility  which  is 
kept  in  view,  and  which  shines  out  upon  every  page, 
together  with  the  skill  which  U  evinced  in  the  com- 
bination of  this  grand  requisite  with  the  utmost 
brevity  which  a  just  treatment  of  the  subjects  would 
admit.— iV.  Y.  Journ.  of  Medicine,  Nov.  1858. 


MONTGOMERY  (W.  F.),    M.  D.,  M.  R.  I.  A.,  &c., 

Professor  of  Midwifery  in  the  King  and  Queen's  College  of  Physicians  m  Ireland,  &c. 

AN  EXPOSITION  OF  THE  SIGNS  AND  SYMPTOMS  OF  PREGNANCY. 

With  some  other  Papers  on  Subjects  connected  with  Midwifery.  From  the  second  and  enlarged 
English  edition.  With  two  exquisite  colored  plates,  and  numerous  wood-cuts.  I"  one  very 
handsome  octavo  volume,  extra  cloth,  of  nearly  600  pages.  (Lately  Published.)  $3  10. 
A  book  unusually  rich  in  practical  suggestions.— 
Am..  Journal  Med.  Sciences,  Jan.  1857. 

These  several  subjects  so  interesting  in  them- 
selves, and  so  important,  every  one  of  them,  to  the 
most  delicate  and  precious  of  social  relations,  con- 
trolling often  the  honor  and  domestic  peace  of  a 
family,  the  legitimacy  of  offspring,  or  the  life  of  its 
parent,  are  all  treated  with  an  elegance  of  diction, 
fulness  of  illustrations,  acuteness  and  justice  of  rea- 
soning, unparalleled  in  obstetrics,  and  unsurpassed  in 
medicine.  The  reader's  interest  can  never  flag,  so 
fresh,  and  vigorous,  and  classical  is  our  author's 
style;  and  one  forgets,  in  the  renewed  charm  of 
every  page,  that  it,  and  every  line,  and  every  word 


has  been  weighed  and  reweighed  through  years  of 
preparation  ;  that  this  is  of  all  others  the  book  of 
Obstetric  Law,  on  each  of  its  several  topics ;  on  all 
points  connected  with  pregnancy,  to  be  everywhere 
received  as  a  manual  of 'special  jurisprudence,  at 
once  announcing  fact,  affording  argument,  establish- 
ing precedent,  and  governing  alike  the  juryman,  ad- 
vocate, and  judge.  It  is  not  merely  in  its  legal  re- 
lations that  we  find  this  work  so  interesting.  Hardly 
a  page  but  that  has  its  hints  or  facts  important  to 
the  general  practitioner  ;  and  not  a  chapter  without 
especial  matter  for  the  anatomist,  physiologist,  or 
pathologist.  — iV.  A.  Med.-Chir.  Review,  March, 
1857. 


MOHR  (FRANCIS),  PH.  D.,  AND  REDWOOD  (TH  EOPH  I  LUS). 
PR  ACTIO -^L    PHARMACY.     Comprising  the  Arrangements,  Apparatus,  and 

M'aninnlation*  of  the  Pharmaceutical  Shop  and  Laboratory.  Edited,  with  extejisive  Additions, 
W  Xtw^LLiAMPKOcTEK,  of  the  PhiLelphra  College  of  Pharmacy.  In  one  handsomely 
printed  octavo  volume,  extra  cloth,  of  570  pages,  with  over  500  engravmgs  ou  wood. 


$2  75, 


24 


BLANCHARD    &    LEA'S    MEDICALi 


NEiLL  (JOHN),   M.  D., 

Surgeon  to  the  Pennsylvania  Hospital,  &c.;  and 

FRANCIS  GURNEY  SMITH,   M.D., 

Professor  of  Institutes  of  Medicine  in  the  Pennsylvania  Medical  College. 

AN  ANALYTICAL  COMPENDIUM  OF  THE  VARIOUS  BRANCHES 

OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.    A  new  edition,  revised 
and  improved.    In  one  very  large  and  handsomely  printed  royal  12mo.  volume,  of  about  one 
thousand  pages,  with  374  wood-cuts.     Strongly  bound  in  leather,  with  raised  bands.     $3  00. 
The  very  flattering  reception  which  has  been  accorded  to  this  work,  and  the  high  estimate  placed 
upon  it  by  the  profession,  as  evinced  by  the  constant  and  increasing  demand  which  has  rapidly  ex- 
hausted two  large  editions,  have  stimulated  the  authors  to  render  the  volume  in  its  present  revision 
more  v/orthy  of  the  success  which  has  attended  it.     It  has  accordingly  been  thoroughly  examined, 
and  such  errors  as  had  on  former  occasions  escaped  observation  have  been  corrected,  and  whatever 
additions  were  necessary  to  maintain  it  on  a  level  with  the  advance  of  science  have  been  introduced. 
The  extended  series  of  illustrations  has  been  still  further  increased  and  much  improved,  while,  by 
a  slight  enlargement  of  the  page,  these  various  additions  have  been  incorporated  without  increasmg 
the  bulk  of  the  volume. 

The  work  is,  therefore,  again  presented  as  eminently  worthy  of  the  favor  with  which  it  has  hitherto 
been  received.  As  a  book  for  daily  reference  by  the  student  requiring  a  guide  to  his  more  elaborate 
text-books,  as  a  manual  for  preceptors  desiring  to  stimulate  their  students  by  frequent  and  accurate 
examination,  or  as  a  source  from  which  the  practitioners  of  older  date  may  easily  and  cheaply  acquire 
a  knowledge  of  the  changes  and  improvement  in  professional  science,  its  reputation  is  permanently 
established. 


The  best  work  of  the  kind  with  which  we  are 
acquainted. — Med.  Examiner. 

Having  made  free  use  of  this  volume  in  our  ex- 
aminations of  pupils,  we  can  speak  from  experi- 
ence in  recommending  it  as  an  admirable  compend 
for  students,  and  as  especially  useful  to  preceptors 
who  examine  their  pupils.  It  will  save  the  teacher 
much  labor  by  enabling  him  readily  to  recall  all  of 
the  points  upon  which  his  pupils  should  be  ex- 
amined. A  work  of  this  sort  should  be  in  the  hands 
of  every  one  who  takes  pupils  into  his  office  with  a 
viewof  examining  them  ;  and  this  is  unquestionably 
the  best  of  its  class. — Transylvania  Med.  Journal. 

In  the  rapijl  course  of  lectures,  where  work  for 


the  students  is  heavy,  and  review  necessary  for  an 
examination,  a  compend  is  not  only  valuable,  but 
it  is  almost  a  sine  qua  non.  The  one  before  us  is, 
in  most  of  the  divisions,  the  most  unexceptionable 
of  all  books  of  the  kind  that  we  know  of.  The 
newest  and  soundest  doctrines  and  the  latest  im- 
provements and  discoveries  are  explicitly,  though 
concisely,  laid  before  the  student.  There  is  a  class 
to  whom  we  very  sincerely  commend  this  cheap  book 
as  worth  its  weight  in  silver — that  class  is  the  gradu- 
ates in  medicine  of  more  than  ten  years'  standing, 
who  have  not  studied  medicine  since.  They  will 
perhaps  find  out  from  it  that  the  science  is  not  exactly 
now  what  it  was  when  they  left  it  off. — The  Stetho- 
scope. 


NELIGAN  (J.    IVIO9RE),  M.  D.,  M.  R.  I. A.,  &.C, 

(A  S'plendid  work.     Just  Issued.) 

ATLAS  OF  CUTANEOUS  DISEASES.     In  one  beautiful  quarto  volume,  extra 
cloth,  with  splendid  colored  plates,  presenting  nearly  one  hundred  elaborate  representations  of 

disease.    $4  50. 

This  beautiful  volume  is  intended  as  a  complete  and  accurate  representation  of  all  the  varieties 
of  Diseases  of  the  Skin.  While  it  can  be  consulted  in  conjunction  with  any  work  on  Practice,  it  has 
especial  reference  to  the  author's  "  Treatise  on  Diseases  of  the  Skin,"  so  favorably  received  by  the 
profession  some  years  since.  The  publishers  feel  justified  in  saying  that  few  more  beautifully  exe- 
cuted plates  have  ever  been  presented  to  the  profession  of  this  country. 


Neligan's  Atlas  of  Cutaneous  Diseases  supplies  a 
long  existent  desideratum  much  felt  by  the  largest 
class  of  our  profession.  It  presents,  in  quarto  size, 
16  plates,  each  containing  from  3  to  6  figures,  and 
forming  in  all  a  total  of  90  distinct  representations 
of  the  different  species  of  skin  affections,  grouped 
together  in  genera  or  families.  The  illustrations 
have  been  taken  from  nature,  and  have  been  copied 
with  such  fidelity  that  they  present  a  striking  picture 
of  life;  in  which  the  reduced  scale  aptly  serves  to 


give,  at  a  coup  d'ceil,  the  remarkable  peculiarities 
of  each  individual  variety.  And  while  thus  the  dis- 
ease is  rendered  more  definable,  there  is  yet  no  loss 
of  proportion  incurred  by  the  necessary  concentra- 
tion. Each  figure  is  highly  colored,  and  so  truthful 
has  the  artist  been  that  the  most  fastid  ous  observer 
could  not  justly  take  exception  to  the  correctness  of 
the  execution  of  the  pictures  under  his  scrutiny. — 
Montreal  Med.  Chronicle. 


BY  THE  SAME  AUTHOR. 

A    PRACTICAL   TREATISE    ON   DISEASES   OF  THE   SKIN. 

American  edition.    In  one  neat  royal  12mo.  volume,  extra  cloth,  of  334  pages.     $1  00. 

|i^"  The  two  volumes  will  be  sent  by  mail  on  receipt  of  Five  Dollars. 


Third 


OWEN    ON    THE    DIFFERENT    FORMS    OF  I 
THE  SKELETON,  AND   OF   THE   TEETH. 


One  vol.  royal  12mo.,  extra  cloth  with  numerous 
illustrations.    $1  3S. 


P I  RRIE  (WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE    PRINCIPLES  AND  PRACTICE  OF  SURGERY.    Edited  by  John 

Neill,  M.  D.,  Professor  of  Surgery  in  the  Penna.  Medical  College,  Surgeon  to  the  Pennsylvania 
Hospital,  &c.  In  one  very  handsome  octavo  volume,  leather,  of  780  pages,  with  316  illustrations. 
$3  75. 


We  know  of  no  other  surgical  work  of  a  reason- 
able size,  wherein  there  is  so  much  theory  and  prac- 
tice, or  where  subjects  are  more  soundly  or  clearly 
taught. — The  Stethoscope. 

Prof.  Pirrie,  in  the  work  before  us,  has  elabo- 


rately discussed  the  principles  of  surgery,  and  a 
safe  and  effectual  practice  predicated  upon  them. 
Perhaps  no  work  upon  this  subject  heretofore  issued 
is  so  full  upon  the  science  of  the  art  of  surgery. — 
Nashville  Journal  of  Medicine  and  Surgery. 


AND  SCIENTIFIC    PUBLICATIONS. 


25 


PARRISH    (EDWARD), 
Lecturer  on  Practical  Pharmacy  and  Materia  Mediea  in  the  Pennsylvania  Academy  of  Medicine  &c 

AN  INTRODUCTION  TO  PRACTICAL  PHARMACY.    Designed  as  a  Text- 

Book  for  the  Student,  and  as  a  Guide  for  the  Physician  and  Pharmaceutist.  With  many  For- 
mulse  and  Prescriptions.  Second  edition,  greatly  enlarged  and  improved.  In  one  handsome 
octavo  volume  of  720  pages,  with  several  hundred  Illustrations,  extra  cloth.  $3  50.  (Now 
Keady.) 

During  the  short  time  in  which  this  work  has  been  before  the  profession,  it  has  been  received 
with  very  great  favor,  and  in  assuming  the  posiiion  of  a  standard  authority,  it  has  filled  a  vacancy 
which  had  been  severely  felt.  Stimulated  by  this  encouragement,  the  author,  in  availing  himself 
of  the  opportunity  of  revision,  has  spared  no  pains  to  render  it  more  worthy  of  the  confidence  be- 
stowed upon  it,  and  his  assiduous  labors  have  made  it  rather  a  new  book  than  a  new  edition,  many 
portions  having  l^een  rewritten,  and  much  new 'and  important  matter  added.  These  alterations  and 
improvements  have  been  rendered  necessary  by  the  rapid  progress  made  by  pharmaceutical  science 
during  the  last  few  years,  and  by  tbe  additioiaal  experience  obtained  in  the  practical  use  of  the 
volume  as  a  text-book  and  work  of  reference.  To  accommodate  these  improvements,  the  size  of 
the  page  has  been  materially  enlarged,  and  the  number  of  pages  considerably  increased,  pre>enting 
in  all  nearly  one-half  more  matter  than  the  last  edition.  The  work  is  therefore  now  presented  as  a 
complete  exponent  of  the  subject  in  its  most  advanced  condition.  From  the  most  ordinary  matters 
in  the  dispensing  office,  to  the  most  complicated  details  of  the  vegetable  alkaloids,  it  is  hoped  that 
everything  requisite  to  the  practicing  physician,  and  to  the  apothecary,  will  be  found  fully  and 
clearly  set  forth,  and  that  the  new  matler  alone  will  be  worth  more  than  the  very  moderate  cost  of 
the  work  to  those  who  have  been  consulting  the  previous  edition. 

That  Edward  Parrish,  in  writing  a  book  upon  there  is  no  production  of  the  kind  in  the  En?Iish 
pracJjcaZ  Pharmacy  some  few  years  ago — one  emi- 
nently original  and  unique — did  the  medical  and 
pharmaceutical  professions  a  great  and  valuable  ser- 
vice, no  one,  \y&  think,  who  has  had  access  to  its 
pages  will  deny  ;  doubly  welcome,  then,  is  this  new 
edition,  containing  the  added  results  of  his  recent 
and  rich  experience  as  an  observer,  teacher,  and 
practicil  operator  in  the  pharmaceutical  laboratory. 
The  excellent  plan  of  the  first  is  more  thoroughly, 
and  in  detail,  carried  out  in  this  edition. — Peninsular 
Med.  Journal,  Jan.  18G0. 

We  know  of  no  -work  on  the  subject  which  would 
be  more  indispensable  to  the  physician  or  student 
desiring  information  on  the  subject  of  which  it  treats. 
"^Viih  Griffith's  "  Medical  Formulary"  and  this,  the 
practising  physician  would  be  supplied  with  nearly 
or  quite  all  the  most  useful  infomation  on  the  sub- 
ject.— Charleston  Med.  Journal  and  Review,  Jan. 
1S60. 

This  edition,  now  much  enlarged,  is  one  of  the 
most  useful  w^orks  of  the  past  year. — N.  0.  Med. 
and  Surg.  Journal,  Jan.  1860. 

The  whole  treatise  is  eminently  practical;   and 


language  so  well  adapted  to  the  wants  of  the  phar- 
maceutist and  druggist.  To  physicians,  also,  it  can- 
not fail  to  l)e  highly  valuable,  especially  to  those 
w^ho  are  obliged  to  prepare  and  compound  many  of 
their  own  medicines. — N.  Am.  Med.  Chir.  Review, 
Jan.  1860. 

Of  course,  all  apothecaries  who  have  not  already 
a  copy  of  the  first  edition  will  procure  one  of  this; 
it  is,  therefore,  to  physicians  residing  in  the  country 
and  in  small  towns,  who  cannot  avail  themselves  of 
the  skill  of  an  educated  pharmaceutist,  that  we 
would  especially  commend  this  work.  In  it  they 
will  find  all  that  they  desire  to  know,  and  should 
kno'W,  but  very  little  of  ■which  they  do  really  inow 
in  reference  to  this  important  collateral  branch  of 
their  profession ;  for  it  is  a  well  established  fact, 
that,  in  the  ecufation  of  physicians,  while  the  sci- 
ence of  medicine  is  generally  well  taught,  very 
little  attention  is  paid  to  the  art  of  preparing  them 
for  use,  and  we  know  not  how  this  defect  can  be  so 
■well  remedied  as  by  procuring  and  consulting  Br. 
Pairish's  excellent  work. — St.  Louis  Med.  Journal. 
Jan. 1S60. 


PEASLEE  (E.  R.),   M.  D., 

Professor  of  Physiology  and  General  Pathology  in  the  New  York  Medical  College. 

HUMAN  HISTOLOG-Y,  in  its  relations  to  Anatomy,  Physiology,  and  Pathology; 

for  the  use  of  Medical  Students.    With  four  hundred  and  thirty- four  illustrations.    In  one  hand- 
some octavo  volume,  of  over  600  pages.     {Lately  Fublished.)     $3  75. 

It  embraces  a  library  upon  the  topics  discussed  j  AVe  would  recommend  it  to  the  medical  student 
within  itself,  and  is  just  what  the  teacher  and  learner  ;  and  practitioner,  as  containing  a  summary  of  all  that 
need.  Another  advantage,  by  no  means  to  be  over-  {  is  known  of  the  important  subjects  wiiich  it  treats  ; 
looked,  everything  of  real  value  in  the  wide  rasge  !  of  all  that  is  contained  in  the  great  works  of  Simon 
which  it  embraces,  is  with  great  skill  compressed  {  and  Lehmann,  and  tlie  organic  chemists  in  general, 
into  an  octavo  volume  of  but  little  more  than  six  j  Master  this  one  volume,  we  would  say  to  the  medical 
hundred  pages.  We  have  not  only  the  whole  sub-  I  student  and  practitioner— master  this  book  and  you 
ject  of  Histology,  interesting  in  itself,  ably  and  fully  '  know  all  that  is  known  of  the  great  fundamental 
discussed,  but  what  is  of  infinitely  greater  interest  |  principles  of  medicine,  and  we  have  no  hesitation 
to  the  student,  because  of  greater  practical  value,  in  saying  that  it  is  an  honor  to  the  American  medi- 
ate its  relations  to  Anatomy,  Physiology,  and  Pa-  !  cal  profession  that  one  of  its  members  should  have 
thology,  which  are  here  fully  and  satisfactorily  set  [produced  it.— Si.  Louis  Mid.  and  Surg.  Journal, 
forth.— Nashville  Journ.  of  Med.  and  Surgery ,  Dec.  March,  1358. 
1857.  [ 

PEREIRA  (JONATHAN),  M.  D.,  F.  R.  S.,  AND  L.  S. 

THE    ELEMENTS    OF   MATERIA    MEDICA   AND    THERAPEUTICS. 

Third  American  edition,  enlarged  and  improved  by  the  author;  including  Notices  of  most  of  the 
Medicinal  Substances  in  use  in  the  civilized  world,  and  forming  an  Encyelopadia  ol  Materia 
Mediea.  Edited,  with  Additions,  by  Joseph  Carson,  M.  D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.  In  two  very  large  octavo  volumes  ol  210U  pages, 
on  small  type,  with  about  500  illustrations  on  stone  and  v/ood,  strongly  bound  m  leather,  with 
raised  bands.  Sy  00. 
j^*,ji.  Vol.  II.  will  no  longer  be  sold  separate. 


PARKER  (LANGSTON), 

Surgeon  to  the  Queen's  Hospital,  Birmingham. 

THE  MODERN  TREATMENT  OF  SYPHILITIC  DISEASES,  BOTH  PRI- 
MARY AND  SECONDARY;  comprisingtheTreatmentof  Constitutional  and  Confirmed  Syphi- 
lis bv  a  safe  and  successful  method.  With  numerous  Cases,  Formula,  and  Clinical  Observa- 
tions. From  the  Third  and  entirely  rewritten  London  edition.  In  one  neat  octavo  volume, 
extra  cloth,  of  316  pages.    $1  75. 


26 


BLANCHARD    &    LEA'S   MEDICAL 


RAMSBOTHAM  (FRANCIS  H.),  M.D. 
THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDICINE  AND 

SURGERY,  in  reference  to  the  Process  of  Parturition.  A  new  and  enlarged  edition,  thoroughly 
revised  by  the  Author.  With  Additions  by  W.  V.  Keating,  M.  D.  In  one  large  and  handsome 
imperial  octavo  volume,  of  650  pages,  strongly  bound  in  leather,  vi^ith  raised  bands;  with  sixty- 
four  beautiful  Plates,  and  numerous  Wood-cuts  in  the  text,  containing  in  all  nearly  two  hundred 
large  and  beautiful  figures.   $5  00. 

From  Prof.  Hodge,  of  the  University  of  Pa. 
To  the  American  public,  it  is  most  valuable,  from  its  intrinsic  undoubted  excellence,  and  as  being 

the  best  authorized  exponent  of  British  Midwifery.    Its  circulation  will,  I  trust,  be  extensive  throughout 

our  country. 


It  is  unnecessary  to  say  anything;  in  regard  to  the 
utility  of  this  virork.  It  is  already  appreciated  in  our 
country  for  the  value  of  the  matter,  the  clearness  of 
its  style,  and  the  fulness  of  its  illustrations.  To  the 
physician's  library  it  is  indispensable,  while  to  the 
student  as  a  text- book,  from  which  to  extract  the 
material  for  laying  the  foundation  of  an  education  on 
obstetrical  science,  it  has  no  superior. — Ohio  Med. 
and  Surg.  Journal. 

The  publishers  have  secured  its  success  by  the 


truly  elegant  style  in  which  they  have  brought  it 
out,  excelling  themselves  in  its  production,  espe- 
cially in  its  plates.  It  is  dedicated  to  Prof.  Meigs, 
and  has  the  emphatic  endorsement  of  Prof.  Hodge, 
as  the  best  exponent  of  British  Midwifery.  We 
knt.w  of  no  text-book  which  deserves  in  all  respects 
to  be  more  highly  recommended  to  students,  and  w.e 
could  wish  to  see  it  in  the  hands  of  every  practitioner, 
for  they  will  find  it  invaluable  for  reference. — Med. 
G-azetie. 


RICORD  (P.),   M.  D. 
A  TREATISE  ON  THE  VENEREAL  DISEASE.    By  John  Hunter,  F.  R.  S. 

With  copious  Additions,  by  Ph.  Ricord,  M.  D.    Translated  and  Edited,  with  Notes,  by  Freeman 
J.  BuMSTEAD,  M.  D  ,  Lecturer  on  Venereal  at  the  College  of  Physicians  and  Surgeons,  New  York. 
Second  edition,  revised,  containing  a  resume  of  Ricord's  Recent  Lectures  on  Chancre.     In 
one  handsome  octavo  volume,  extra  cloth,  of  550  pages,  with  eight  plates.   $3  25.    {Just  Issued.) 
In  revising  this  work,  the  editor  has  endeavored  to  introduce  whatever  matter  of  interest  the  re- 
cent investigations  of  syphilographers  have  added  to  our  knowledge  of  the  subject.     The  principal 
source  from  which  this  has  been  derived  is  the  volume  of  "Lectures  on  Chancre,"  publi:^lled  a  few 
months  since  by  M.  Ricord,  which  affords  a  large  amount  of  new  and  instructive  material  on  many 
controverted  points.     In  the  previous  edition,  M.  Ricord's  additions  amounted  to  nearly  one-third 
of  the  whole,  and  with  the  matter  now  introduced,  the  work  may  be  considered  to  present  his  views 
and  experience  more  thoroughly  and  completely  than  any  other. 

secretaries,  sometimes  accredited  and  sometimes  not. 
In  the  notes  to  Hunter,  the  master  substitutes  him- 
self for  his  interpreters,  and  gives  hisoriginal  thoughts 
to  the  world  in  a  lucid  and  perfectly  intelligible  man- 
ner.    In  conclusion  we  can  say  that  this  is  incon- 


Every  one  will  recognize  the  attractiveness  and 
value  which  this  work  derives  from  thus  presenting 
the  opinions  of  these  two  masters  side  by  side.  But, 
it  must  be  admitted,  what  has  made  the  formne  of 
the  book,  is  the  fact  that  it  contains  the  "most  com- 
plete embodiment  of  the  veritable  doctrines  of  the 
Hopital  du  Midi,"  which  has  ever  been  made  public. 
The  doctrinal  ideas  of  M.  Ricord,  ideas  which,  if  not 
universally  adopted, are  incoiuesiably  dominant,  have 
heretofore  only  been  interpreledby  more  or  less  skilful 


testably  the  best  treatise  on  syphilis  with  v/hieh  we 
are  acquainted,  and,  as  v^e  do  not  often  employ  the 
phrase,  we  may  be  excused  for  expressing  the  hope 
that  it  may  find  a  place  in  the  library  of  every  phy- 
sician.—  Virginia  Med.  and  Surg.  Journal. 


BY   THE  SAME   AUTHOR. 

RICORD'S  LETTERS  ON  SYPHILIS.   Translated  by  W.  P.  Lattimore,  M.  D. 
In  one  neat  octavo  volume,  of  270  pages,  extra  cloth.    $2  00. 


ROYLE'S   MATERIA   MEDICA   AND   THERAPEUTICS;   including  the 

Preparations  of  the  Pharmacopoeias  of  London,  Edinburgh,  Dublin,  and  of  the  United  States. 
^With  many  new  medicines.  Edited  by  Joseph  Carson,  M.  D.  With  ninety-eight  illustrations. 
In  one  large  octavo  volume,  extra  cloth,  of  about  700  pages.    S.^  00. 


ROKITANSKY 

Curator  of  the  Imperial  Pathological  Museum, 

A   MANUAL   OF  PATHOLOGICAL 

bound  in  two,  extra  cloth,  of  about  1200  pages. 
KING,  C.  H.  Moore,  and  G.  E.  Day.  $5  50 
The  profession  is  too  well  acquainted  with  the  re- 
putation of  Rokitansky's  work  to  need  our  assur- 
ance that  this  is  one  of  themostprofound,  thorough, 
and  valuable  books  ever  issued  from  the  medical 
press.  It  is  sui  generis,  and  has  no  standard  of  com- 
parison. It  is  only  necessary  to  announce  that  it  is 
issued  in  a  form  as  cheap  as  is  compatible  with  its 
size  and  preservation,  and  its  sale  follows  as  a 
matter  of  course.  No  library  can  be  called  com- 
plete without  it. — Buffalo  Med.  Journal. 

An  attempt  to  give  our  readers  any  adequate  idea 
of  the  vast  amount  of  instruction  accumulated  in 
these  volumes,  w^ould  be  feeble  and  hopeless.  The 
effort  of  the  distinguished  author  to  concentrate 
in  a  small  space  his  great  fund  of  knowledge,  has 


(CARL),    M.  D,, 

and  Professor  at  the  University  of  Vienna,  &c. 

ANATOMY.     Four  volumes,   octavo. 

Translated  by  W.  E.  Swaine,  Edward  Sieve- 
so  charged  his  text  with  valuable  truths,  that  any 
attempt  of  a  reviewer  to  epitomize  is  at  once  para- 
lyzed, and  must  end  in  a  failure. — Western  Lancet. 

As  this  is  the  highest  source  of  knowledge  upon 
the  important  subject  of  which  it  treats,  no  real 
student  can  afford  to  be  without  it.  The  American 
piiblishers.have  entitled  themselves  to  the  thanks  of 
the  profession  of  their  country,  for  this  timeous  and 
beautiful  edition. — Nashville  Journal  of  Medicine. 

As  a  book  of  reference,  therefore,  this  work  must 
prove  of  inestimable  value,  and  we  cannot  too  highly 
recommend  it  to  the  profession. — Charleston  Med. 
Journal  and  Review. 

This  book  is  a  necessity  to  every  practitioner. — 
Am.  Med.  Monthly. 


RIGBY    (EDWARD),    M.  D., 

Senior  Physician  to  the  General  Lying-in  Hospital,  &c. 

A    SYSTEM    OF    MIDWIFERY.     With  Notes  and  Additional  Illustrations. 

Second  American  Edition.     One  volume  octavo,  extra  clofh,  422  pages.     $2  50. 
BY  THE  SAME  AUTHOR.     (Lately  Publtsked.) 

ON  THE  CONSTITUTIONAL  TREATMENT  OF  FEMALE  DISEASES. 

In  one  neat  royal  12mo.  volume,  extra  cloth,  of  about  250  pages,     f  1  00, 


AND    SCIENTIFIC    PUBLICATIONS. 


27 


STILLE  (ALFRED),    M.D. 
THERAPEUTICS  AND  MATERIA  MEDIC  A;  a  Systematic  Treatise  oa  the 

Action,  and  Uses  of  Medicinal  Agents,  including  their  Description  and  History.    In  two  lar°-e  and 
handsome  octavo  volumes,  of  1789  pages.     (iYow  Ready,  1860.)     $8  00.  ° 

This  work  is  designed  especiallj-  for  the  student  and  practitioner  of  medicine,  and  treats  the  various 
articles  of  the  Materia  Medica  from  the  point  of  view  of  the  bedside,  and  not  of  the  shop  or  of  the 
lecture-room.  While  thus  endeavoring  to  give  all  practical  information  likely  to  be  useful  with 
respect  to  the  employment  of  special  remedies  in  special  affections,  and  the  results  to  be  anticipated 
from  their  administration,  a  copious  Index  of  Diseases  and  their  Remedies  renders  the  work  emi- 
nently fitted  tor  reference  by  showing  at  a  glance  ihe  different  means  which  have  been  employed, 
and  enabling  the  practitioner  to  extend  his  resources  in  difficult  ca>es  with  all  that  the  experience 
of  the  protession  has  suggested.  At  the  same  time  particular  care  has  been  given  to  the  subject 
of  General  Therapeutics,  and  at  the  commencement  of  each  class  of  medicines  there  is  a  chapter 
devoted  to  the  consideration  of  their  common  influence  upon  morbid  conditions.  The  action  of 
remedial  agents  upon  the  healthy  economy  and  on  animals  has  likewise  received  particular  notice, 
from  the  conviction  that  their  physiological  efiects  will  afford  frequent  explanations  of  their  patho- 
logir!al  influence,  and  in  many  cases  lead  to  new  and  important  suggestions  as  to  their  practical  use 
in  disease.  Within  the  scope  thus  designed  by  the  author,  no  labor  has  been  spared  to  accumulate 
all  the  facts  which  have  accrued  from  the  experience  of  the  profession  in  all  ages  and  all  countries  ; 
and  the  vast  amount  of  recent  researches  recorded  in  the  periodical  literature  of  both  hemispheres 
has  been  zealously  laid  under  contribution,  resulting  in  a  mass  of  practical  information  scarcely 
attempted  hitherto  in  any  similar  work  in  the  language. 


Our  expectations  of  the  value  of  this  work  were 
based  on  the  well-known  reputation  and  character 
of  the  author  as  a  man  of  scholarly  attainments,  an 
elegant  writer,  a  candid  inquirer  after  truth,  and  a 
philosophical  thmker ;  we  knew  that  the  task  would 
be  conscientiously  performed,  and  that  i^Vf,  if  any, 
among  the  distinguished  medical  teachers  in  this 
country  are  better  qualified  than  he  to  prepare  a 
systenatic  treatise  on  therapeutics  in  accordance 
with  the  present  requirements  of  medical  science. 
Our  preliminary  examination  of  the  work  has  satis- 
fied us  that  we  were  not  mistaken  in  our  anticipi- 
tions.  In  congratulating  the  author  on  the  comple- 
tion of  the  great  labor  which  such  a  work  involves, 
we  are  happy  m  expressing  the  conviction  that  its 
merits  will  receive  that  reward  which  is  above  all 
price—  the  grateful  appreciation  of  his  medical  bre- 
thren.— I^iw  Orleans  Medical  News,  Marcli,  1S60. 

We  think  this  work  will  do  much  to  obviate  the 
reluctance  to  a  thorough  investigation  of  this  branch 
of  scientific  study,  for  in  the  wide  range  of  medical 
literature  treasured  in  the  English  tongue,  we  shall 
hardly  find  a  work  written  in  a  style  more  clear  and 
simple,  conveying  forcibly  the  facts  taught,  and  yet 
free  from  turgidity  and  redundancy.  There  is  a  fas- 
cination in  its  pages  that  will  insure  to  it  a  wide 
popularity  and  attentive  perusal,  and  a  degree  of 
usefulness  not  often  attained  through  the  influence 
of  a  single  work.     The  author  has  much  enhanced 


the  practical  utility  of  his  book  by  passing  hriefly 
over  the  physical,  botani  ;al,  and  commercial  history 
of  medicines,  and  directiiig  attention  chiefly  to  their 
physiological  action,  and  their  application  for  che 
amelioration  or  cure  of  disease.  He  ignores  hypothe- 
sis and  theory  -^vhich  are  so  alluring  to  many  medical 
writers,  and  so  liable  to  lead  them  astray,  and  eon- 
fines  himself  to  such  facts  as  have  been  tried  in  the 
crucible  of  experience. — Chicago  Medical  Journal, 
March,  1860. 

The  plan  pursued  by  the  author  in  these  very  ela- 
borate volumes  is  not  strictly  one  of  scientific  unity 
and  precision  ;  he  has  rather  subordinated  these  to 
practical  utility.  Dr.  Stille  has  produced  a  work 
which  will  he  valuable  equally  to  the  student  of 
medicine  and  the  busy  practitioner.— Lonrfora  Lan- 
cet, March  10,  1860. 

With  Pereira,  Dunglison,  Mitchell,  and  Wood  be- 
fore us,  we  may  well  ask  if  there  was  a  necessity 
for  a  new  book  on  the  subject.  After  examining  this 
work  with  some  care,  we  can  answer  aifinnatively . 
Dr.  Wood's  book  is  well  adapted  for  students,  while 
Dr.  Stille's  will  be  more  satisfactory  to  the  practi- 
tioner, who  desires  to  study  the  action  of  medicines. 
The  author  needs  no  encomiums  from  us,  for  he  is 
well  known  as  a  ripe  scholar  and  a  man  of  the  most 
extensive  reading  in  his  profession.  This  work  bears 
evidence  of  this  fact  on  every  page. — Cincinnati 
Lancet,  April,  ls60. 


SMITH    (HENRY    H.),   M.D. 
MINOR  SURG-ERY;  or,  Hints  on  the  Every-day  Duties  of  the  Surgeon.     With 

247  illustrations.    Third  edition.    1  vol.  royal  12mo.,  pp.  456.    In  leather,  $2  25;  cloth,  $2  00. 

BY   THE  SAME   AUTHOR,   AND 

HORNER  (WILLIAM  E.),  M.  D., 
Late  Professor  of  Anatomy  in  the  University  of  Pennsylvania. 

AN  ANATOMICx\L  ATLAS,  illustrative  of  the  Structure  of  the  Human  Body. 

In  one  volume,  large  imperial  octavo,  extra  cloth,  with  about  six  hundred  and  fifty  beautiful 
figures.     $3  00. 


These  figures  are  well  selected,  and  present  a 
complete  and  accurate  representation  of  that  won- 
derful fabric,  the  human  body.  The  plan  of  this 
Atlas,  which  renders  it  so  peculiarly  convenient 
for  the  student,  and  its  superb  artistical  execution, 
have  been  already  pointed  out.     We  must  congratu- 


late the  student  upon  the  eoKpletion  of  this  Atlaa, 
as  it  is  the  most  convenient  work  of  the  kind  that 
has  yet  appeared  ;  and  we  must  add,  the  very  beau- 
tiful manner  in  which  it  is  "got  up"  is  so  creditable 
to  the  country  as  to  be  flattering  to  our  national 
pride. — American  Medical  Journal. 


SHARPEY  (WILLIAM),   M.  D.,   JONES   QUAIN,   M.  D.,  AND 

RICHARD  QUAIN,   F.  R.  S.,  &c. 

HUMAN  ANATOMY.     Revised,  with  Notes  and  Additions,  by  Joseph  Leidy, 

M  D  ,  Professor  of  Anatomy  in  the  University  of  Pennsylvania.  Complete  in  two  large  octavo 
volumes,  leather,  of  about  thirteen  hundred  pages.  Beautifully  illustrated  with  over  five  hundred 
engravings  on  wood.     $6  00. 

SIMPSON  (J.  Y.  ,   M.  D., 

Professor  of  Midwifery,  &c.,  in  the  University  of  Edinhurgh,  &c. 

CLINICAL  LECTURES  ON  THE  DISEASES  OP  FEMALES.     With  numc- 

rous  illustrations. 

This  valuable  series  of  practical  Lectures  is  now  appearing  in  the  "Medical  News  and 
Library"  for  1860,  and  can  thus  be  had  without  cost  by  subscribers  to  the  "Aivierican  Journal 
OF  THE  Medical  Sciences."    See  p.  2. 


28 


BLANCHARD    &   LEA'S    MEDICAL 


SARGENT  (F.  W.),   M.  D. 
ON  BANDAaiNa  AND  OTHER  OPERATIONS  OP  MINOR  SURGERY. 

Second  edition,  enlarged.     One  handsome  royal  12mo.  vol.,  of  nearly  400  pages,  with  182  wood- 
cuts.    Extra  cloth,  f  1  40 ;  leather,  $1  50. 


Sargent's  Minor  Surgery  has  always  been  popular, 
and  deservedly  so.  It  furnishes  that  knowledge  of  the 
most  frequently  requisite  performances  of  surgical 
art  which  cannot  be  entirely  understood  by  attend- 
ing clinical  lectures.  The  art  of  bandaging,  which 
is  regularly  taught  in  Europe,  is  very  frequently 
overlooked  by  teachers  in  this  country  ;  the  student 
and  junior  practitioner,  therefore,  may  often  require 
that  knowledge  which  this  little  volume  so  tersely 
and  happily  supplies. — Charleston  Med.  Journ.  and 
Review^  March,  1856. 


A  work  that  has  been  so  long  and  favorably  known 
to  the  profession  as  Dr.  Sargent's  Minor  Surgery, 
needs  no  commendation  from  us.  We  would  remark, 
however,  in  this  connection,  that  minor  surgery  sel- 
dom gets  that  attention  in  our  schools  that  its  im- 
portance deserves.  Our  larger  w^orks  are  also  very 
defective  in  their  teaching  on  these  small  practical 
points.  This  little  book  will  supply  the  void  which 
all  must  feel  who  have  not  siudied  its  pages. — West- 
ern Lancet,  March,  1856. 


SMITH  (W.   TYLER),  M.  D., 

Physician  Accoucheur  to  St.  Mary's  Hospital,  &c. 

ON   PARTURITION,   AND   THE   PRINCIPLES   AND   PRACTICE   OF 

OBSTETKICS.    In  one  royal  12mo.  volume,  extra  cloth,  of  400  pages.    $125. 

BY  THE  SAME  AUTHOR. 

A  PRACTICAL  TREATISE  ON  THE  PATHOLOGY  AND  TREATMENT 

OF  LEUCORKHCEA.    With  numerous  illustrations.    In  one  very  handsome  octavo  volume, 
extra  cloth,  of  about  250  pages,     f  1  50. 


SOI-LY  ON  THE  HUMAN  BRAIN;  its  Structure, 
PJiysiology,  and  Diseases.  From  the  Second  and 
mucti  enlarged  London  edition.  In  one  octavo 
volume,  extra  cloth,  of  500  pages,  with  liO  wood- 
cuts.   f2  00. 

SKEY'S  OPERATIVE  SURGERY.    In  one  very 


handsome  octavo  volume,  extra  cloth,  of  over  650 
pages,  with  about  one  hundred  wood-cuts.  $3  25. 
SIMON'S  GENERAl.  PATHOLOGY,  as  conduc- 
ive to  the  Establlstiment  of  Rational  Principles 
for  the  preventiim  and  Cure  of  Disease.  In  one 
octavo  volume,  extra  cloth,  of  212  pages.    $1  25. 


TODD  (R.   B.),   M.D.,    F.  R.  S.,   &c. 
CLINICAL  LECTURES  ON  CERTAIN  DISEASES  OP  THE  URINARY 

ORGANS  AND  ON  DROPSIES.    In  one  octavo  volume,  284  pages,    f  1  50. 

BY  THE  SAME  AUTHOR.       {NoVI  Ready.) 

CLINICAL  LECTURES  ON  CERTAIN  ACUTE  DISEASES.     In  one  neat 

octavo  A^olume,  of  320  pages,  extra  cloth,     fl  75. 

The  subjects  treated  in  this  volume  are — Rheumatic  Fever,  Continued  Fever,  Erysipelas, 
Acute  Internal,  Inflammation,  Pyaemia,  Pneumonia,  and  the  Therapeutical  Action  of  Alco- 
hol. The  importance  of  these  matters  in  the  daily  practice  of  every  physician,  and  the  sound 
practical  nature  of  Dr.  Todd's  writings,  can  hardly  fail  to  attract  to  this  work  the  general  attention 
that  it  merits. 


TANNER   (T.    HJ,    M.  D., 

Physician  to  the  Hospital  for  Women,  &c. 

A  MANUAL  OP  CLINICAL  MEDICINE  AND  PHYSICAL  DIAGNOSIS. 

To  which   is  added  The  Code   of  Ethics   of  the  American    Medical  Association.     Second 
American  Edition.    In  one  neat  volume,  small  12mo.,  extra  cloth,  87^  cents. 


TAYLOR  (ALFRED  S.),  M.  D.,  F.  R.  S., 

Lecturer  on  MedicalJurisprudence  and  Chemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDENCE.     Fourth  American  Edition.     With  Notes  and 

References  to  American  Decisions,  by  Edward  Hartshorne,M.  D.   In  one  large  octavo  volume, 
leather,  of  over  seven  hundred  pages.     $3  00. 


No  work  upon  the  subject  can  be  put  into  the 
hands  of  students  either  of  law  or  medicine  which 
will  engage  them  more  closely  or  profitably  ;  and 
none  could  be  offered  to  the  busy  practitioner  of 
either  calling,  for  the  purpose  of  casual  or  hasty 
reference,  that  would  be  more  likely  to  afford  the  aid 
desired.  We  therefore  recommend  it  as  the  best  and 
safest  manual  for  daily  \i.&e.— American  Journal  oj 
Medical  Sciences. 


It  is  not  excess  of  praise  to  say  that  the  volume 
before  us  is  the  very  best  treatise  extant  on  Medical 
Jurisprudence.  In  saying  this,  we  do  not  wish  to 
be  understood  as  detracting  from  the  merits  of  the 
excellent  works  of  Beck,  Ryan,  Traill,  Guy,  and 
others;  but  in  interest  and  value  we  think  it  must 
be  conceded  that  Taylor  is  superior  to  anything  that 
has  preceded  it.— JV.  W.  Medical  and  Surg.  Journal. 


BY  THE  SAME  AUTHOR.     (New  Edition,  just  issiied.') 

ON  POISONS,  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.    Second  American,  from  a  second  and  revised  London  edition.     In  one  large 

octavo  volume,  of  755  pages,  leather.    $3  50. 

Since  the  first  appearance  of  this  work,  the  rapid  advance  of  Chemistry  has  introduced  into 
use  many  new  substances  which  may  become  fatal  through  accident  or  design  —  while  at  the 
same  time  it  has  likewise  designated  new  and  more  exact  modes  of  counteracting  or  detecting  those 
previously  treated  of.  Mr.  Taylor's  position  as  the  leading  medical  jurist  of  England,  has  during 
this  period  conferred  on  him  extraordinary  advantages  in  acquiring  experience  on  these  subjects, 
nearly  all  cases  of  moment  being  referred  to  him  for  examination,  as  an  expert  whose  testimony 
is  generally  accepted  as  final.  The  results  of  his  labors,  therefore,  as  gathered  together  in  this 
volume,  carefully  weighed  and  sifted,  and  presented  in  the  clear  and  intelligible  style  for  which 
he  is  noted,  may  be  received  as  an  acknowledged  authoritj-,  and  as  a  guide  to  be  followed  with 
implicit  confidence. 


AND    SCIENTIFIC    PUBLICATIONS.  29 


TODD  (ROBERT  BENTLEY),  M .  D.,  F.  R.  S., 

Professor  of  Physiology  in  King's  College,  London;  and 

WILLIAM  BOWMAN,  F.  R.  S., 

Demonstrator  of  Anatomy  in  King's  College,  London. 

THE  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF  MAN.    With 

about  three  hundred  large  and  beautiful  illustrations  on  wood.     Complete  in  one  large  octavo 
volume,  of  950  pages,  leather.     Price  $4  50. 

B^  Gentlemen  who  have  received  portions  of  this  work,  as  published  in  the  "  Medical  News 
AND  Library,"  can  now  complete  their  copies,  if  immediate  application  be  made.  It  will  be  fur- 
nished as  follows,  free  by  mail,  in  paper  covers,  with  cloth  backs. 

Parts  I.,  II.,  III.  (pp.  25  to  552),  $2  50. 

Part  IV.  (pp.  553  to  end,  with  Title,  Preface,  Contents,  &c.),  $2  00. 

Or,  Part  IV.,  Section  II.  (pp.  725  to  end,  with  Title,  Preface,  Contents,  &c.),  $1  25. 

A  magnificent  contribution  to  British  medicine, 
and  the  American  physician  who  shall  fail  to  peruse 
it,  wih  have  failed  to  read  one  of  the  most  instruc 


tive  books  of  the  nineteenth  century. — N.  O.  Med. 
and  Surg.  Journal,  Sept.  1S57. 

It  is  more  con  else  than  Carpenter's  Principles,  and 
more  modern  than  the  accessible  edition  of  Mailer's 
Elements;  its  details  are  brief,  but  sufficient;  its 
descriptions  vivid  ;  its  illustrations  exact  and  copi- 
ous ;    and  its  language  terse  and  perspicuous. 

Charleston  Med.  Journal,  July,  1857. 

We  know  of  no  work  on  the  subject  of  physiology 


so  well  adapted  to  the  wants  of  the  medical  student. 
Its  completion  has  been  thus  long  delayed,  that  the 
authors  might  secure  accuracy  by  personal  observa- 
tion.— St.  Louis  Med.  and  Surg.  Journal,  Sept.  '57. 

Our  notice,  though  it  conveys  but  a  very  feeble 
and  imperfect  idea  of  the  magnitude  and  importance 
of  the  work  now  under  consideration,  already  tran- 
scends our  limits  ;  and,  with  the  indulgence  of  our 
readers,  and  the  hope  that  they  will  peruse  the  book 
for  themselves,  as  v/e  feel  we  can  with  confidence 
recommend  it,  we  leave  it  in  their  hands.  —  The 
Northwestern  Med.  and  Surg.  Journal. 


TOYNBEE  (JOSEPH),   F.  R.  S., 

Aural  Surgeon  to,  and  Lecturer  on  Surgery  at,  St.  Mary's  Hospital. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  EAR;  their  Diag- 
nosis, Pathology,  and  Treatment.  Illustrated  with  one  hundred  engravings  on  wood.  In  one 
very  handsome  octavo  volume,  extra  cloth,  $3  00.     {Now  Ready.) 

Mr.  Toyn bee's  name  is  too  widely  known  as  the  highest  authority  on  all  matters  connected  wiik 
Aural  Surgery  and  Medicine,  to  require  special  attention  to  be  called  to  anything  which  he  may 
communicate  to  the  profession  on  the  subject.  Twenty  years'  labor  devoted  to  the  present  work 
has  embodied  in  it  the  results  of  an  amount  of  experience  and  observation  which  perhaps  no  other 
living  practitioner  has  enjoyed.  It  theretbre  cannot  fail  to  prove  a  complete  and  trustworthy  guide 
on  all  matters  connected  with  this  obscure  and  little  known  class  of  diseases,  which  so  frequently 
embarrass  the  general  practitioner. 

Tne  volume  will  be  found  thoroughly  illustrated  with  a  large  number  of  original  wood-engrav- 
ings, elucidating  the  pathology  of  the  organs  of  hearing,  instruments,  operations,  &c.,  and  in  every 
respect  it  is  one  of  the  handsomest  specimens  of  mechanical  execution  issued  from  the  American 
press. 

The  following  condensed  sjmopsis  of  the  contents  will  show  the  plan  adopted  by  the  author,  and 
the  completeness  with  which  all  departments  of  the  subject  are  brought  under  consideration. 
CHAPTER  I.  Introduction— Mode  of  Investigation— Dissection.  II.  The  External  Ear — Ana- 
tomy— Pathology — Malformations  —  Diseases.  III.  The  External  Meatus  —  Its  Exploration. 
IV.  The  External  Meatus — Foreign  Bodies  and  Accumulations  of  Cerumen.  V.  The  External 
Meatus — The  Dermis  and  its  Diseases.  VI.  The  External  Meatus — Polypi.  VII.  The  External 
Meatus — Tumors.  VIII.  The  Membrana  Tympani — Structure  and  Functions.  IX.  The  Mem- 
brana  Tympani — Diseases.  X.  The  Membrana  Tympani — Diseases.  XI.  The  Eustachian 
Tube — Obstructions.  XII.  The  Cavity  of  the  Tympanum — Anatomy — Pathology — Diseases. 
XIII.  The  Cavity  of  the  Tympanum— Diseases.  XIV.  The  Mastoid  Cells— Diseases.  XV. 
The  Diseases  of  the  Nervous  Apparatus  of  the  Ear,  producing  what  is  commonly  called  "  Nerv- 
ous Deafness."  XVI.  The  Diseases  of  the  Nervous  Apparatus,  continued.  XVII.  Malignant 
Disease  of  the  Ear.  XVIII.  On  the  Deaf  and  Dumb.  XIX.  Ear-Trumpets  and  their  uses. 
Appendix. 

WILLIAMS  (G.   J.   B.),    M.D.,    F.  R.S., 

Professor  of  Clinical  Medicine  in  University  College,  London,  &c. 

PRINCIPLES  OF  MEDICINE.     An  Elementaiy  View  of  the  Causes,  Nature, 

Treatment,  Diagnosis,  and  Prognosis  of  Disease;  with  brief  remarks  on  Hygienics,  or  the  pre- 
servation of  health.  A  new  American,  from  the  third  and  revised  London  edition,  in  one  octavo 
volume,  leather,  of  about  500  pages.     S2  50.     {Just  IssJied.) 


We  find  that  the  deeply-interesting  matter  and 
style  of  this  book  have  so  far  fascinated  us,  that  we 
have  unconsciously  hung  upon  its  pages,  not  too 
long,  indeed,  for  our  own  profit,  but  longer  than  re- 
viewers can  be  permitted  to  indulge.  We  leave  the 
further  analysis  to  the  student  and  practitioner.  Our 
judgment  of  the  v/ork  has  already  been  sufficiently 


expressed.    It  is  u  judgment  of  almost  unqualified 
praise. — London  Lancet. 

A  test-book  to  which  no  other  in  our  language  is 
comparable. — Charleston  Medical  Journal. 

No  work  has  ever  achieved  or  maintained  a  more 
deserved  reputation.— Fa.  Med.  and  Surg.  Journal. 


WHAT   TO   OBSERVE 
AT    THE    BEDSIDE    AND    AFTER  DEATH,   IN    MEDICAL   CASES. 

Published  under  the  authority  of  the  London  Society  for  Medical  Observation.    A  new  American, 

from  the  second  and  revised  London  edition.    In  one  very  handsome  volume,  royal  12mo.,  extra 

cloth.    $1  00. 

To  the  observer  who  prefers  accuracy  to  blunders  i  One  of  the  finest  aids  to  a  yo«°J  PJ„a«'i^'°'?^^T  y« 
afid  precision  to  carelessness,  this  little  book  is  :n-  hsive  eyeTatea.-Femnsvlar  Journal  of  Medicmi. 
valuable.— iV.  S.  Journal  of  Medicim.  < 


30 


BLANCHARD   &   LEA'S    MEDICAL 


New  and  much  enlarged  edition— (Just  Issued.) 
k^j-  WATSON   (THOMAS),    M.D.,    &c., 

Late  Physician  to  the  Middlesex  Hospital,  &c. 

LECTURES    ON    THE   PRINCIPLES    AND    PRACTICE   OF   PHYSIC. 

Delivered  at  King's  College,  London.     A  new  American,  from  the  last  revised  and  enlarged 

English  edition,  with  Additions,  by  D.  Francis  Condie,  M.  D.,  author  of  "  A  Practical  Treatise 

on  the  Diseases  of  Children,"  &c.     With  one  hundred  and  eighty.five  illustrations  on  wood.     In 

one  very  large  and  handsome  volume,  imperial  octavo,  of  over  1200  closely  printed  pages  in 

small  type ;  the  whole  strongly  bound  in  leather,  with  raised  bands.     Price  $4  25. 

That  the  high  reputation  of  this  work  might  be  fully  maintained,  the  author  has  subjected  it  to  a 

thorough  revision ;  every  portion  has  been  examined  with  the  aid  of  the  most  recent  researches 

in  pathology,  and  the  results  of  modern  investigations  in  both  theoretical  and  practical  subjects 

have  been  carefully  weighed  and  embodied  throughout  its  pages.     The  watchful  scrutiny  of  the 

editor  has  likewise  introduced  whatever  possesses  immediate  importance  to  the  American  physician 

in  relation  to  diseases  incident  to  our  climate  which  are  little  known  in  England,  as  well  as  those 

points  in  which  experience  here  has  led  to  different  modes  of  practice  ;  and  he  has  also  added  largely 

to  the  series  of  illustrations,  believing  that  in  this  manner  valuable  assistance  may  be  conveyed  to 

the  student  in  elucidating  the  text.     The  work  will,  therefore,  be  found  thoroughly  on  a  level  with 

the  most  advanced  state  of  medical  science  on  both  sides  of  the  Atlantic. 

The  additions  which  the  wo]k  has  received  are  shown  by  the  tact  that  notwithstanding  an  en- 
largement in  the  size  of  the  page,  more  than  two  hundred  additional  pages  have  been  necessary 
to  accommodate  the  two  large  volumes  of  the  London  edition  (which  sells  at  ten  dollars),  within 
the  compass  of  a  single  volume,  and  in  its  present  form  it  contains  the  matter  of  at  least  three 
ordinary  octavos.  Believing  it  to  be  a  work  which  should  lie  on  the  table  of  every  physician,  and 
be  in  the  hands  of  every  student,  the  publishers  have  put  it  at  a  price  within  the  reach  of  all,  making 
it  one  of  the  cheapest  books  as  yet  presented  to  the  American  profession,  while  at  the  same  time 
the  beauty  of  its  mechanical  execution  renders  it  an  exceedingly  attractive  volume. 

The  fourth  edition  now  appears,  so  carefully  re- 
vised, as  to  add  considerably  to  the  value  of  a  book 
already  acknowledged,  wlierever  the  English  lan- 
guage is  read,  to  be  beyond  all  comparison  the  best 
systematic  work  on  the  Principles  and  Practice  of 
Physic  in  the  whole  range  of  medical  literature. 
Every  lecture  contains  proof  of  the  extreme  anxiety 
of  the  author  to  keep  pace  wich  'he  advancing  know- 
ledge of  the  day,  and  to  bring  the  results  of  the 
labors,  not  only  of  physicians,  but  of  chemists  and 
histologists,  before  his  readers,  wherever  they  can 
be  turned  to  useful  account.  And  this  is  done  with 
such  a  cordial  appreciation  of  the  merit  due  to  the 
industrious  observer,  such  a  generous  desire  to  en- 
courage younger  and  rising  men,  and  such  a  candid 
acknowledgment  of  his  own  obligations  to  them, 
that  one  scarcely  knows  whether  to  admire  most  the 
pure,  simple,  forcible  English — the  vast  amount  of 
useful  practical  information  condensed  into  the 
Lectures — or  the  manly,  kind-hearted,  unassuming 
character  of  the  lecturer  shining  through  his  work. 
— London  Med.  Times  and  Gazette,  Oct.  31,  1857. 

Thus  these  admirable  volumes  come  before  the 
profession  in  their  fourth  edition,  abounding  in  those 
distinguished  attributes  of  moderation,  judgment, 
erudite  cultivation,  clearness,  and  eloquence,  with 
which  they  were  from  the  first  invested,  but  yet 
richer  than  before  in  the  results  of  more  prolonged 
observation,  and  in  the  able  appreciation  of  the 
latest  advances  in  pathology  and  medicine  by  one 
of  the  most  profound  medical  thinkers  of  the  day. — 
London  Lancet,  Nov.  14,  1857. 


The  lecturer's  skill,  his  wisdom,  his  learning,  are 
equalled  by  the  ease  of  his  graceful  diction,  his  elo- 
quence, and  the  far  higher  qualities  of  candor,  of 
courtesy,  of  modesty,  and  of  generous  appreciation 
of  merit  in  others.  IVIay  Le  long  remain  to  instruct 
us,  and  to  enjoy,  in  the  glorious  sunset  of  his  de- 
clining years,  the  honors,  the  confidence  and  love 
gained  during  his  useful  life.— iV.  A.  Med.-Chir. 
Review,  July,  1858. 

Watson's  unrivalled,  perhaps  unapproachable 
work  on  Practice — the  copious  additions  made  to 
which  (the  fourth  edition)  have  given  it  all  the  no- 
velty and  much  of  the  interest  of  a  new  book. — 
Charleston  Med.  Journal,  July,  1858. 

Lecturers,  practitioners,  and  students  of  medicine 
will  equally  hail  the  reappearance  of  the  work  of 
Dr.  Watson  in  the  form  of  anew — a  fourth — edition. 
We  merely  do  justice  to  our  own  feelings,  and,  we 
are  sure,  of  the  whole  profession,  if  we  thank  him 
for  having,  in  the  trouble  and  turmoil  of  a  large 
practice,  made  leisure  to  supply  the  hiatus  caused 
by  the  exhaustion  of  the  pu])lisher's  stock  of  the 
third  edition,  which  has  been  severely  felt  for  the 
last  three  years.  For  Dr.  Watson  has  not  merely 
caused  the  lectures  to  be  reprinted,  but  scattered 
through  the  whole  work  we  find  additions  or  altera- 
tions which  prove  that  the  author  has  in  every  way 
sought  to  bring  up  his  teaching  to  the  level  of  che 
most  recent  acquisitions  in  science. — Brit,  and  For. 
Medico-Chir.  Review,  Jan.  1853. 


WALSHE  (W.    H.),   M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London,  &c. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  LUNGS;  includiog 

the  Principles  of  Physical  Diagnosis.    A  new  American,  from  the  third  revised  and  much  en- 
larged London  edition.     In  one  vol.  octavo,  of  468  pages.    {Just  Issued,  June,  1860.)     $2  25. 
The  present  edition  has  been  carefully  revised  and  much  enlarged,  and  may  be  said  in  the  main 
to  be  rewritten.     Descriptions  of  several  diseases,  previously  omitted,  are  now  introduced ;  the 
causes  and  mode  of  production  of  the  more  important  affections,  so  far  as  they  possess  direct  prac- 
tical significance,  are  succinctly  inquired  into ;  an  effort  has  been  made  to  bring  the  description  of 
anatomical  characters  to  the  level  of  the  wants  of  the  practical  physician  ;  and  the  diagnosis  and 
prognosis  of  each  complaint  are  more  completely  considered.     The  sections  on  Treatment  and 
the  Appendix  (concerning  the  influence  of  climate  on  pulmonary  disorders),  have,  especially,  been 
largely  extended. — Author''s  Preface. 
,j;;*^  To  be  followed  by  a  similar  voltmie  on  Diseases  of  the  Heart  and  Aorta. 


WILSON  (ERASMUS),   F.  R.  S., 

Lectureron  Anatomy,  London. 

THE    DISSECTOR'S  MANUAL;  or,  Practical  and  Surgical  Anatomy.     Third 

American,  from  the  last  revised  and  enlarged  English  edition.  Modified  and  rearranged,  by 
William  Hunt,  M.  D.,  Demonstrator  of  Anatomy  in  the  University  of  Pennsylvania.  In  one 
large  and  handsome  royal  12mo.  volume,  leather,  of  582  pages,  with  154  illustrations.    $2  00. 


AND    SCIENTIFIC    PUBLICATIONS  31 


Ne-w  and  much  enlarged  edition — (Just  Issued.) 
WILSON  (ERASMUS),  F.  R.  S. 
A  SYSTEM  OF  HUMAN  ANATO:\IY,  General  and  Special.  A  new  and  re- 
vised American,  from  the  last  and  enlarged  Engli-h  Edition.  Edited  by  W.  H.  Gobrecht,  M.  D., 
Profe>sor  of  Anatomy  in  the  Pennsylvania  IVIedical  College,  &e.  Illustrated  with  three  hundred 
and  ninety-seven  engravings  on  wood.  In  one  large  and  exquisitely  printed  octavo  volume,  oi 
over  600  large  pages;  leather.     $3  25. 

The  publishers  trust  that  the  well  earned  reputation  so  long  enjoyed  by  this  work  will  be  more 
than  maintained  by  the  present  edition.  Besides  a  very  thorough  revision  by  the  author,  it  ha*  been 
most  carefully  examined  by  the  editor,  and  the  eflbrts  of  both  have  been  directed  to  introducing 
everything  which  increased  experience  in  its  use  has  suggested  as  desirable  to  render  it  a  complete 
text-book  for  those  seeking  to  obtain  or  to  renew  an  acquainiance  with  Human  Anatomy.  The 
amount  of  additions  which  it  has  thus  received  may  be  estimated  from  the  fact  that  the  present 
edition  contains  over  one-fourth  more  matter  than  the  last,  rendering  a  smaller  type  and  an  enlaro-ed 
page  requisite  to  keep  the  volume  withm  a  convenient  size.  The  author  has  not  only  thus  added 
largely  to  the  work,  but  he  has  also  made  alterations  throughout,  wherever  there  appeared  the 
opportunity  of  improving  the  arrangement  or  style,  so  as  to  present  every  fact  in  its  most  appro- 
priate manner,  and  to  render  the  whole  as  clear  and  intelligible  as  possible.  The  editor  has 
exercised  the  utmost  caution  to  obtain  entire  accuracy  in  the  text,  and  has  largely-  increased  the 
number  of  illustrations,  of  which  there  are  about  one  hundred  and  fifty  more  in  this  edition  than 
in  the  last,  thus  bringing  distinctly  before  the  eye  of  the  student  everything  of  interest  or  importance. 


It  may  be  recommended  to  the  student  as  no  less 
distinguished  by  its  accuracy  and  clearness  of  de- 
scription than  by  its  t^'pographical  elegance.  The 
wood-cuts  are  exquisite. — Brit,  and  For.  Medical 
Review. 

An  elegant  edition  of  one  of  the  most  useful  and 
accurate  systems  of  anatomical  science  which  has 
been  issued  from  the  press  The  illustrations  are 
really  beautiful.  In  its  style  the  work  is  extremely 
concise  and  intelligible.     No  one  can  possibly  take 


beauty  of  its  mechanical  execution,  and  the  clear- 
ness of  the  descriptions  which  it  contains  is  equally 
evident.  Let  students,  by  all  means  e.xamine  tne 
claims  of  this  work  on  their  notice,  before  they  pur- 
chase a  text-book  of  the  vitally  important  science 

which  this  volume  so  fully  and  easily  unfolds. 

Lancet. 

We  regard  it  as  the  best  system  now  extant  for 
students. — Western  Lancet. 

It  therefore  receives  our  highest  commendation. 


up  this  volume  without  being  struck  with  the  great  |  Southern  Med.  and  Surg.  Journal. 
BY  THE  SAME  AUTHOR.     (JT.st  Issued.) 

ON  DISEASES  OE  THE  SKIN.     Fourth  and  enlarged  American,  from  the  last 

and  improved  London  edition.     In  one  large  octavo  volume,  of  650  pages,  extra  cloth,  $2  75. 

Thewritingsof  AVilson,  upondiseasesof  the  skin,  |  at  some  of  the  more  salient  points  with  which  it 
are  by  far  the  most  scientific  and  practical  that  j  abounds,  and  which  make  it  incompuraoiy  superior  in 
iiave  ever  been  presented  to  the  medical  world  on  j  excellence  to  all  other  treatises  on  the  subject  of  der- 
thissubject.  The presenteditionisagreat  improve-  |  matology.  No  mere  speculative  view?  are  allowed 
ment  on  all  its  predecessors.  To  dwell  upon  all  the  a  place  in  this  volume,  whicli,  without  a  doubt,  will 
great  merits  and  high  claims  of  the  work  before  us.  '  for  a  ver}-  long  period,  be  acknowledged  as  the  chiei" 
seriatim,  ■wou\d  indved  be  an  agreeable  service ;  it  !  standard  work  on  dermatology.  The  principles  of 
would  be  a  mental  homage  which  we  could  freely  1  an  enlightened  and  rational  therapeia  are  introduced 
offer,  but  we  should  thus  occupy  an  undue  amount  |  on  every  appropriate  occasion. — Am.  Jour.  Med. 
ot  space  in  this  Journal.    We  will,  however,  look  ■  Science,  Oct.  1S57. 

ALSO,  NOW  READY, 

A  SERIES  OF  PLATES  ILLUSTEATINa  WILSON  ON  DISEASES  OF 

THE  SKIN  ;  consisting  of  nineteen  beautifulh' executed  plates,  of  which  twelve  are  exquisitely 
colored,  presenting  the  Normal  Anatomy  and  Pathology  of  the  Skin,  and  containing  accurate  re- 
presentations of  about  one  hundred  varieties  of  disease,  most  of  them  the  size  of  nature.  Price 
in  cloth  §4  25. 

la  beauty  of  drawing  and  accuracy  and  finish  of  coloring  these  plates  will  be  found  equal  to 
anything  of  the  kind  as  yet  issued  in  this  country. 
The  plates  by  which  this  edition  is  accompanied 


We  have  already  expressed  our  high  appreciation 
of  Mr.  Wilson's  treatise  on  Diseases  of  the  Skin. 
The  plates  are  comprised  in  a  separate  volume, 
which  we  counsel  all  those  who  possess  the  text  to 
purchase.  It  is  a  beautiful  specimen  of  color  print- 
in;;,  and  the  repiesentations  of  the  various  forms  of 
skin  disease  are  as  faithful  as  is  possible  in  plates 
of  the  size. — Boston  Med.  and  Surg.  Journal,  April 
8,  1858. 


leave  nothing  to  be  desired,  so  far  as  excellence  of 
delineation  and  perfect  accuracy  of  1 1  Lustration  are 
eoncerned. — Medico-Chirurgical  Review. 

Of  these  plates  it  is  impossible  to  speak  too  highly 
The  representations  of  the  various  forms  of  cutane- 
ous disease  are  singularly  accurate,  and  the  color- 
ing exceeds  almost  anything  we  have  met  with  in 
point  of  delicacy  and  &msh.— British  and  Foreign 
Medical  Review. 

BY  THE  SAME  AUTHOR. 

ON    CONSTITUTIONAL    AND    HEREDITARY    SYPHILIS,  AND    ON 

SYPHILITIC  EPtUPTIONS.    In  one  small  octavo  volume,  extra  cloth,  beautifully  printed,  with 
four  exquisite  colored  plates,  presenting  more  than  thirty  varieties  ol'  syphilitic  eruptions.  $2  25, 

BY   THE  SAME  AUTHOR. 

HEALTHY  SKIN;  A  Popular  Treatise  on  the  Skin  and  Hair,  their  Preserva- 
tion and  Management.  Second  American,  from  the  fourth  London  edition.  One  neat  volume, 
royal  12mo.,  extra  cloth,  of  about  .300  pages,  with  numerous  illustrations.  SI  00  ;  paper  cover, 
75  cents. 


WHITEHEi*D  ON  THE  CAUSES  AND  TREAT-  |     Second  American  Edition.    In  one  volame,  octa- 
MENT  OF    ABORTION    AND  STERILITY.  J     vo  extra  cloth,  pp.  308.    ?1    75. 


32 


BLANCHARD   &   LEA'S    MEDICAL    PUBLICATIONS. 


WINSLOW   (FORBES),   M.D.,    D.C.L.,   &.c. 

ON  OBSCURE  DISEASES  OF  THE  BRAIN  AND  DISORDERS  OF  THE 

MIND;  their  incipient  Symptoms,  Paliiology,  Diagnosis,  Treatment,  and  Prophylaxis.  In  one 
handsome  octavo  volume,  of  nearly  600  pages.  [Just  Issued,  June,  1660.)  $3  00. 
The  momentous  questions  discussed  in  this  volume  have  perhaps  not  hitherto  been  so  ably  and 
elaborately  treated.  Dr.  Winslov^^'s  distinguished  reputation  and  long  experience  in  everything  re- 
lating to  insanity  invest  his  teachings  with  the  highest  authority,  and  in  this  carefully  considered 
volume  he  has  drawn  upon  the  accumulated  resources  of  a  life  of  observation.  His  deductions 
are  founded  on  a  vast  number  of  cases,  the  peculiarities  of  which  are  related  in  detail,  rendering 
the  work  not  onljr  one  of  sound  instruction,  but  of  lively  interest;  the  author's  main  object  being 
to  point  out  the  connection  between  organic  disease  and  insanity,  tracing  the  laiter  through  all  its 
stages  from  mere  eccentricity  to  mania,  and  urging  the  necessity  of  early  measures  of  prophylaxis 
and  appropriate  treatment.  A  subject  of  greater  importance  to  society  at  large  could  .'careely  be 
named  ;  while  to  the  physician  who  may  at  any  moment  be  called  upon  for  interference  in  the  most 
delicate  relations  of  life,  or  for  an  opinion  in  a  court  of  justice,  a  work  like  the  present  rray  be  con- 
sidered indispensable. 

The  treatment  of  the  subject  may  be  gathered  from  the  following  summary  of  the  contents : — 
Chapter  I.  Introduction. — II.  Morbid  Phenomena  of  Intelligence.  III.  Premonitory  Symptoms 
of  Insanity. — IV.  Confessions  of  Patients  after  Recovery. — V.  State  of  the  Mind  during  Re- 
covery.— VI.  Anomalous  and  Masked  Affections  of  the  Mind. — VII.  The  Stage  of  Consciousness. 
— Vlil.  Stage  of  Exaltation. — IX.  Stage  of  Mental  Depression. — X.  Siage  of  Aberration. — XI. 
Impairmeiit  of  Mind. — XII.  Morbid  Phenomena  of  Attention. — XIII.  Morbid  Phenomena  of 
Memory — XIV.  Acute  Disorders  of  Memory. — XV.  Chronic  Affections  of  Memory. — XVI. 
Perversion  and  Exaltalion  of  Memory. — XVII.  Psychology  and  Pathology  of  Memory. — XVIII. 
Morbid  Phenomena  of  Molion. — XIX.  Morbid  Phenomena  of  Speech. — XX.  Morbid  Phenomena 
of  Sensa'ion. — XXI.  Morbid  Phenomena  of  the  Special  Senses. — XXII.  Morbid  Phenomena  of 
Vision,  Hearing,  Taste,  Touch,  and  Smell. — XXIII.  Morbid  Phenomena  of  Sleep  and  Dreaming. 
— XXIV.  Morbid  Phenomena  of  Organic  and  Nutritive  Life. — XXV.  General  Principles  of  Pa- 
thology, Diagnosis,  Treatment,  and  Prophylaxis. 


WEST   (CHARLES),    M.  D., 

Accoucheur  to  and  Lecturer  on  Midwifery  at  St.  Bartholomew's  Hospital,  Physician  to  the  Hospital  foi 

Sick  Children,  &c. 

LECTURES  ON  THE  DISEASES  OF  WOMEN.     Now  complete  in  one  hand- 

some  octavo  volume,  extra  cloth,  of  about  500  pages;  price  $2  50. 

Also,  for  sale  separate,  Part  II,  being  pp.  309  to  end,  with  Index,  Title  matter, 

&c.,  8vo.,  cloth,  price  f  1. 


and  children  is  not  to  be  found  in  any  country.— 
Soutkern  Med.  and  Surg.  Journal,  January  185S.  <"' 

We  gladiy  recommend  his  Lectures  as  in  the  high- 
est degree  instructive  to  all  who  are  interested  in 
obstetric  practice. — London  Lancet. 

We  have  to  say  of  it,  briefly  and  decidedly,  that 
it  is  the  best  work  on  the  subject  in  any  language; 
and  that  it  stamps  Dr.  West  as  1\\q  facile  jirincepi 
of  British  obstetric  authors. — Edinb.  Med.  Journ, 


We  must  now  conclude  this  hastily  written  sketch 
with  the  confident  assurance  to  our  readers  that  the 
work  will  well  repay  perusal.  The  conscientious, 
painstaking,  practical  ptiysician  is  apparent  dh  every 
page. — iV.  Y.  Journal  of  Medicine,  March,  1858. 

We  know  of  no  treatise  of  the  kind  so  complete 
and  yet  so  compact. — Chicago  Med.  Journal,  Janu- 
ary, 1858. 

A  fairer,  more  honest,  more  earnest,  and  more  re- 
liable investigator  of  the  many  diseases  of  women 

BY    THE   SAME   AUTHOR.      (Now  Ready.) 

LECTURES   ON   THE   DISEASES    OP  INFAiNCY  AND  CHILDHOOD. 

Third  American,  from  the  fourth  enlarged  and  improved  London  edition.     In  one  handsome 
octavo  volume,  extra  cloth,  of  about  six  hundred  and  fifty  pages.     $2  75. 

The  continued  favor  with  which  this  work  has  been  received  has  stimulated  the  author  to  ren- 
der it  in  every  respect  more  complete  and  more  worthy  the  confidence  of  the  profession.  Con- 
taining nearly  two  tiundred  pages  more  than  the  last  American  edition,  with  !?everal  additional 
Lectures  and  a  careful  revision  and  enlargement  of  those  formerly  comprised  in  it,  it  can  hardly 
tail  to  maintain  its  reputation  as  a  clepr  and  judicious  text-book  for  the  student,  and  a  safe  and 
reliable  guide  for  the  practitioner.  The  fact  stated  by  the  author  that  these  Lectures  '■  now  embody 
the  re;rulls  of  900  observations  and  288  post-mortem  examinations  made  among  nearly  30,000 
children,  who,  during  the  past  twenty-years,  have  come  under  my  care,"  is  sufficient  to  show  their 
high  practical  value  as  the  result  of  an  amount  of  experience  which  few  physicians  enjoy. 


The  three  former  editions  of  the  work  now  before 
us  have  placed  the  author  in  tne  foremost  rank  of 
those  physicians  who  have  devoted  special  attention 
to  tJie  diseases  of  early  life  We  attempt  no  ana- 
1>  sis  of  this  edition,  but  may  refer  the  reader  to  some 
of  the  chaptei's  to  which  the  largest  additions  have 
been  made — those  on  Diphtheria,  Disorders  of  the 
iVIind,  and  Idiocy,  for  instance — as  a  proof  that  the 
work  is  really  a  new  edition;  not  a  mere  roprint. 
In  its  pref  ent  shape  it  will  be  found  of  the  greatest 
possible  service  in  the  every-day  practice  of  nine- 
tenths  of  the  profession. — Med.  Times  and  G-azetie, 
London,  Dec.  10,  1859. 

All  things  considired,  this  book  of  Dr.  West  is 
by  far  the  best  treatise  in  our  language  upon  such 
modihsations  of  morbid  action  and  disease  as  are 
witnt.ssed  when  we  have  to  deal  with  infancy  and 
childhood.  It  is  true  that  it  confines  itself  to  such 
disorders  as  come  within  the  proviace  of  the  phy- 
sician, and  even  with  respect  to  these  it  is  unequal 
as  regards  minuteness  of  consideration,  and  some 


diseases  it  omits  to  notice  altogether.  But  those 
who  know  anything  of  the  present  condition  of 
paediatrics  will  readily  admit  chat  it  would  be  next 
to  impossible  to  effect  more,  or  effect  it  better,  than 
the  accoucheur  of  St.  Bartholomew's  has  done  in  a 
single  volume.  The  lecture  (XVI.)  upon  Disorotrs 
of  the  Mind  in  children  is  an  admirable  specimen  of 
the  value  of  the  later  information  conve}ed  in  the 
Lectures  of  Dr.  Charles  West. — London  Lancet, 
Oct.  22,  1859. 

Since  the  appearance  of  the  first  edition,  about 
eleven  years  ago,  the  experience  of  the  author  has 
doubled ;  so  that,  v^hereas  the  lentures  at  first  were 
founded  on  six  hundred  observations,  and  one  hun- 
dred and  eigmy  dissections  made  among  nearly  four- 
teen thousand  children,  they  now  embody  the  results 
of  nine  hundred  observations,  and  two  hundred  and 
eighty-eig:htpost-niortem  examinations  made  among 
nearly  thirty  thousand  children,  who,  during  the 
past  twenty  years,  have  been  under  his  care. — 
British  Med.  Journal,  Oct.  1,  1859. 


BY  THE  SAME  AUTHOR. 

AN  ENQUIRY  INTO  THE  PATHOLOaiCAL  IMPORTANCE  OP  ULCER- 
ATION OF  THE  OS  TJTERI.    In  one  neat  octavo  volume,  extra  cloth.    $1  00. 


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